Medical Director, Utilization Management - Appeals & Grievances

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.

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 California
• Requires 2 years of previous medical leadership experience
• Requires 5 years of direct patient care experience post residency
• Requires maintaining Board Certification in an ABMS or AOA recognized specialty; Internal Medicine or Family Practice is preferred
• 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/Procedures development, Clinical Subject Matter Expert for Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management and Population Health
• Completed residency in adult based primary care specialty (e.g., Internal medicine, Family practice) is preferred
• Demonstrated experience working within Commercial and Medicare health plan environments is preferred
• 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
• Strong ability to comprehend and interpret medical policies and apply them consistently in clinical decision-making
• Strong written communication skills, with the ability to prepare clear, concise, and well-supported clinical determinations, appeal decisions, and professional correspondence
• Proficient in the use of computer applications and technology required to support utilization management, appeals, documentation, and data review activities
• Strong 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.

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 requirements
• Conduct 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 guidelines
• Provide clinical consultation and subject matter expertise to internal departments
• Apply 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 members
• Participate 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 members
• Participate in cross-functional projects, committees, and workgroups as needed, providing clinical expertise and contributing to organizational initiatives, process improvements, and strategic objectives
• Demonstrate 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 manner
• Understand, follow, and uphold departmental policies and procedures, the organization''s Standards of Conduct, and the Corporate Compliance Program in all aspects of work
• Successfully complete all mandatory training and educational requirements
• Adhere to all applicable state and federal laws, regulations, and organizational policies in the performance of job duties
• Perform other assigned duties as assigned

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 requirements
• Conduct 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 guidelines
• Provide clinical consultation and subject matter expertise to internal departments
• Apply 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 members
• Participate 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 members
• Participate in cross-functional projects, committees, and workgroups as needed, providing clinical expertise and contributing to organizational initiatives, process improvements, and strategic objectives
• Demonstrate 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 manner
• Understand, follow, and uphold departmental policies and procedures, the organization''s Standards of Conduct, and the Corporate Compliance Program in all aspects of work
• Successfully complete all mandatory training and educational requirements
• Adhere to all applicable state and federal laws, regulations, and organizational policies in the performance of job duties
• Perform other assigned duties as assigned