Medical Director, Utilization Management - Appeals & Grievances

Blue Shield of California•Rancho Cordova, CA

3d•$234,630 - $336,600•Hybrid

About The Position

The Medical Director, Utilization Management - Appeals and Grievances is a key member of Blue Shield of California's Clinical Appeals and Grievance Program and reports directly to the Senior Medical Director of Appeals and Grievances. The role provides clinical review of member appeals for Medicare and Commercial lines of business, ensuring timely and compliant appeal determinations. The Medical Management team works to advance medical, medication, and payment policy in support of a value-based health care system in California. The position conducts independent clinical reviews of member appeals and coverage determinations, assessing medical necessity and benefit eligibility in accordance with health plan policies, regulatory requirements, and clinical guidelines. The Medical Director applies clinical expertise, medical and pharmacy policies, laws and regulations, evidence-based medicine, network requirements, and benefits to make fair, consistent, and defensible determinations. The role also provides clinical consultation, participates in peer-to-peer discussions and cross-functional initiatives, and collaborates with internal teams and external stakeholders. The role allows employees to work virtually full-time, with office attendance based on business need. The position is performed in an office and/or home office environment and is sedentary for most of the workday.

Requirements

Medical degree (M.D. or D.O.).
Active, unrestricted California medical license; an active, unrestricted license in any additional assigned states is required if assigned to states beyond California.
Two years of previous medical leadership experience.
Five years of direct patient care experience after residency.
Maintain board certification in an ABMS- or AOA-recognized specialty.
Demonstrated proficiency in at least three of the following: Medicare/Medicare STARS, Dual Special Needs Plan (D-SNP), Medi-Cal, NCQA/URAC/Quality Programs, policies and procedures development, clinical subject matter expertise for litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management, and Population Health.
Extensive experience performing utilization management activities, including prior authorization, concurrent review, retrospective/post-service review, application of evidence-based clinical criteria, and medical necessity determinations in accordance with regulatory and health plan requirements.
Ability to comprehend and interpret medical policies and apply them consistently in clinical decision-making.
Strong written communication skills, including the ability to prepare clear, concise, well-supported clinical determinations, appeal decisions, and professional correspondence.
Proficiency with computer applications and technology used for utilization management, appeals, documentation, and data review.
Strong collaboration skills to work effectively with diverse, cross-functional teams.

Nice To Haves

Board certification in Internal Medicine or Family Practice is preferred.
Residency completed in an adult-based primary care specialty, such as Internal Medicine or Family Practice, is preferred.
Experience working within Commercial and Medicare health plan environments is preferred.

Responsibilities

Complete assigned appeal reviews and adjudicate member appeals across lines of business and products accurately, efficiently, within required timeframes, and in compliance with applicable regulatory requirements.
Conduct independent clinical reviews of member appeals and coverage determinations to assess medical necessity and benefit eligibility in accordance with health plan policies, regulatory requirements, and clinical guidelines.
Provide clinical consultation and subject matter expertise to internal departments.
Apply clinical expertise, BSC medical and pharmacy policies, state and federal laws and regulations, evidence-based medicine, network requirements, and benefits to ensure fair, consistent, and defensible determinations.
Participate in peer-to-peer discussions with medical directors from delegated provider organizations as needed to review clinical cases, address coverage and medical necessity issues, and reach consensus on care decisions.
Participate in cross-functional projects, committees, and workgroups, providing clinical expertise and contributing to organizational initiatives, process improvements, and strategic objectives.
Collaborate with staff, team members, and stakeholders, fostering productive working relationships and communicating professionally, respectfully, and tactfully.
Follow departmental policies and procedures, the organization's Standards of Conduct, and the Corporate Compliance Program.
Complete mandatory training and educational requirements.
Adhere to applicable state and federal laws, regulations, and organizational policies in performing job duties.
Perform other assigned duties.