Medical Director, Utilization Management - Commercial Prior Authorization Review

Medical Director, Utilization Management Commercial Prior Authorization Review

The Medical Management team ensures that Blue Shield of California (BSC) is on the cutting edge of utilization management reimagined to accelerate the development and sustainability of a value-based health care system in California. 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 BSC Commercial and Medicare members. These functions include performance of pre-service and retrospective utilization review, and operationalization of joint initiatives supporting BSC strategic goals.

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

In this role, you will:

• Complete assigned clinical reviews (preservice requests, 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
• Collaborate with nurse reviewer teams in the implementation and operation of assigned initiatives
• Serve as a clinical, regulatory and quality improvement resources and clinical thought leader within the organization
• Support Vice President, Medical Director in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
• Attend mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Participate actively in assigned Committees and any other assigned duties

Qualifications

Your Knowledge and Experience:

• Requires a Medical degree (M.D./D.O.)
• Requires completed residency preferably in adult based primary care specialty (e.g., Internal medicine, Family practice)
• Requires maintaining an active, unrestricted California State Medical License; Requires maintaining an active, unrestricted Medical License in all additional assigned states required
• Requires maintaining Board Certification in one of ABMS or AOA recognized specialty (preferably Internal Medicine or Family Practice)
• Requires 5 years direct patient care experience post residency
• Requires relevant experience in managed care that can contribute to utilization management, case management, and/or quality improvement activities or other health care administrative operations at the IPA or health plan level
• Demonstrated proficiency in at least three of the following: MEDICARE/MEDICARE STARS, Dual Special Needs Plan (D-SNP), MEDI-CAL, NCQA/URAC/Quality Programs, Policies/Procedure 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 is preferred
• Knowledge and skilled application of National evidence-based medical necessity criteria references (MCG or InterQual)
• 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
• Proficiency with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

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.