Job DescriptionYour RoleThe 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.
ResponsibilitiesYour 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
QualificationsYour 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 WorkThis role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
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.
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