Medical Director, Utilization Management - Appeals & Grievances

Blue Shield of California•Rancho Cordova, CA

22h•Remote

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, 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 requires independent clinical review of appeals and coverage determinations, applying clinical expertise, health plan policies, regulatory requirements, clinical guidelines, evidence-based medicine, network requirements, and member benefits to make fair, consistent, and defensible decisions. The Medical Director also provides clinical consultation and expertise to internal departments and participates in peer-to-peer discussions with medical directors from delegated provider organizations as needed. The role collaborates with staff, team members, and stakeholders; contributes clinical expertise to cross-functional projects and organizational initiatives; and adheres to departmental procedures, the organization’s Standards of Conduct, the Corporate Compliance Program, and applicable laws and regulations. Employees may work virtually full-time, with office attendance expected based on business need.

Requirements

Medical degree (M.D. or D.O.).
Active, unrestricted California State Medical License; an active, unrestricted license in any additional assigned state is required if assigned to states beyond California.
At least 2 years of previous medical leadership experience.
At least 5 years of direct patient care experience after residency.
Maintain board certification in an ABMS- or AOA-recognized specialty.
Demonstrated proficiency in at least 3 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, applying evidence-based clinical criteria, and making 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 preparing 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.
Completion of a residency 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 regulations.
Conduct independent clinical review of member appeals and coverage determinations to assess medical necessity and benefit eligibility under health plan policies, regulatory requirements, and clinical guidelines.
Provide clinical consultation and subject matter expertise to internal departments.
Apply clinical expertise, medical and pharmacy policies, state and federal laws and regulations, evidence-based medicine, network requirements, and benefits to make fair, consistent, and defensible determinations.
Participate as needed in peer-to-peer discussions with medical directors from delegated provider organizations to review cases, resolve coverage and medical necessity issues, and reach consensus on care decisions.
Participate in cross-functional projects, committees, and workgroups, contributing clinical expertise to organizational initiatives, process improvements, and strategic objectives.
Demonstrate sound clinical judgment, decision-making, and problem-solving, along with effective interpersonal and communication skills.
Collaborate with staff, team members, and stakeholders while 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.
Perform other assigned duties.