Medical Director, Utilization Management - Concurrent Review
Apply NowCompany: Blue Shield Of California
Location: San Diego, CA 92154
Description:
Job Description
Your Role
The Medical Management team ensures that Blue Shield 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 will report to the Vice President, Medical Management. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for the membership. These functions include performance of pre-service, concurrent and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.
The Medical Director, Utilization Management facilitates performance management and goals in alignment with organizational goals for the membership. Moreover, the Medical Director, Operations leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California members. You will also provide direction and leadership in compliance with regulatory requirements and key operational metrics and work collaboratively with the Director, Utilization Management to achieve these goals.
Responsibilities
Your Work
In this role, you will:
Qualifications
Your Knowledge and Experience
About the Team
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:
Our Workplace Model:
At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.
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.
Your Role
The Medical Management team ensures that Blue Shield 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 will report to the Vice President, Medical Management. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for the membership. These functions include performance of pre-service, concurrent and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.
The Medical Director, Utilization Management facilitates performance management and goals in alignment with organizational goals for the membership. Moreover, the Medical Director, Operations leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California members. You will also provide direction and leadership in compliance with regulatory requirements and key operational metrics and work collaboratively with the Director, Utilization Management to achieve these goals.
Responsibilities
Your Work
In this role, you will:
- Complete assigned clinical reviews (preservice requests, Concurrent Review, Provider Claims Disputes, pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for the membership as well as other lines of business, including Medicare
- Partner closely with the Sr. Medical Director, Utilization Management to develop improved utilization of effective and appropriate services and support operational implementation of transformation initiatives for the membership
- Support Sr. Medical Director, Concurrent Review in coordinating the care of membership, to provide access to high-quality health care to these members
- Support Sr. Medical Director, Concurrent Review in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
- Collaborate with teams in the implementation and operation of assigned initiatives
- Understands and abides by all departmental policies and procedures as well as the organization's Standards of Conduct and Corporate Compliance Program
- Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
- Participates actively in assigned Committees
- Abides by all applicable laws and regulations as mandated by state and federal laws
- Any other assigned duties
Qualifications
Your Knowledge and Experience
- Medical degree (M.D./D.O.)
- Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
- Maintain active, unrestricted California State Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required
- Maintain Board Certification in one of ABMS or AOA categories required (preferably Internal Medicine or Family Practice)
- Minimum 5 years direct patient care experience post residency
- 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/Population Health, Federal Employee Program (FEP), Education/Training (delivers CME, CEU), Quality Improvement
- Knowledge of Medicare, California statutes and regulations including DMHC. Understanding of NCQA accreditation standards preferred
- Knowledge and skilled application of National evidence-based medical necessity criteria references (MCG or InterQual)
- An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances
- Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications
- Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more
- Excellent written and verbal communication skills
- Excellent analytical, time management and organizational skills
- Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint
About the Team
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:
At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
- Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:
o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.
- On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
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.