Medical Director, Utilization Management - Appeals & Grievances

Job Description Your Role The Medical Management team ensures that Blue Shield of California (BSC) is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Utilization Management - Appeals and Grievances is a key member of BSC's Clinical Appeals and Grievance Program, reporting directly to the Senior Medical Director of Appeals and Grievances. The position provides clinical review of member appeals for Medicare and Commercial lines of business, ensuring timely and compliant appeal determinations. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. Responsibilities Your Work In this role, you will: Complete all assigned appeal reviews and adjudicate member appeals across all lines of business and products accurately, efficiently, and within required timeframes while maintaining full compliance with applicable regulatory requirementsConduct independent clinical review of member appeals and coverage determinations to assess medical necessity and benefit eligibility in accordance with health plan policies, regulatory requirements, and clinical guidelinesProvide clinical consultation and subject matter expertise to internal departmentsApply clinical expertise, BSC medical and pharmacy policies, applicable state and federal laws and regulations, evidence-based medicine, network requirements, and benefits to ensure fair, consistent, and defensible determinations for membersParticipate in peer-to-peer discussions with medical directors from delegated provider organizations as needed to review clinical cases, resolve coverage and medical necessity issues, and achieve consensus on care decisions relating to the care of membersParticipate in cross-functional projects, committees, and workgroups as needed, providing clinical expertise and contributing to organizational initiatives, process improvements, and strategic objectivesDemonstrate strong clinical judgement, decision-making, and problem-solving skills, along with excellent interpersonal and communication abilities Collaborate with staff, team members, and other stakeholders, fostering productive working relationships while communicating in a professional, respectful, and tactful mannerUnderstand, follow, and uphold departmental policies and procedures, the organization's Standards of Conduct, and the Corporate Compliance Program in all aspects of workSuccessfully complete all mandatory training and educational requirementsAdhere to all applicable state and federal laws, regulations, and organizational policies in the performance of job dutiesPerform other assigned duties as assigned Qualifications Your Knowledge and Experience Requires a Medical degree (M.D./D.O.)Requires an active, unrestricted California State Medical License; Active and unrestricted Medical License in all additional assigned states required if assigned to other states in addition to CaliforniaRequires 2 years of previous medical leadership experienceRequires 5 years of direct patient care experience post residencyRequires maintaining Board Certification in an ABMS or AOA recognized specialty; Internal Medicine or Family Practice is preferredDemonstrated proficiency in at least 3 of the following: Medicare/Medicare STARS, Dual Special Needs Plan (D-SNP), Medi-Cal, NCQA/URAC/Quality Programs, Policies/Procedures development, Clinical Subject Matter Expert for Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management and Population HealthCompleted residency in adult based primary care specialty (e.g., Internal medicine, Family practice) is preferredDemonstrated experience working within Commercial and Medicare health plan environments is preferredExtensive 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 requirementsStrong ability to comprehend and interpret medical policies and apply them consistently in clinical decision-makingStrong written communication skills, with the ability to prepare clear, concise, and well-supported clinical determinations, appeal decisions, and professional correspondenceProficient in the use of computer applications and technology required to support utilization management, appeals, documentation, and data review activitiesStrong collaboration skills to effectively work with diverse, cross-functional teams to support organizational goals and successful outcomes Hybrid Virtual Work This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need. About Us About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us! Our Values: Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives. Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. Our Workplace Model We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility: For most teams, this means coming into the office two days per week. Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need. For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being. The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews. Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Please click here for further physical requirement detail. Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws. JOB INFO Job Identification : 20261944 Job Category : Healthcare Services and Operations Posting Date : 2026-10-20T21:53:09+00:00 Job Schedule : Full time Locations : Rancho Cordova, CA, United States CA, United States Long Beach, CA, United States El Dorado Hills, CA, United States Lodi, CA, United States Oakland, CA, United States Redding, CA, United States San Diego, CA, United States Woodland Hills, CA, United States Pay Range for California : $234630.00 to $336600.00 Pay Range for Bay Area : $264492.00 to $379440.00 Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles. Role can be filled by a candidate requiring sponsorship : No