Medical Director, Utilization Management - FEP bei Blue Shield of California Group

Your Work

In this role, you will:

• Provide medical decision-making and support for the prior authorization registered nurse (RN) team, facilitating appropriate use of resources, including safe and timely decisions. These duties will require telephonic physician-to-physician discussions regarding current hospitalized patients. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers

• The Medical Director will review pre- and post-service requests and render decisions based on the member’s benefits, medical necessity, Blue Shield of California medical policy, FEP medical policy, as well as legal and regulatory requirements. The Medical Director must be well-versed with most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency

• The Medical Director will participate on projects and committees as necessary

• Problem analysis and clinical decision-making, which are the most critical skills, including the ability to independently formulate and implement solutions

• 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

• An ability to work in high-pressure situations while maintaining good leadership and reasoning ability

• Strong collaboration skills to effectively work as a team that consist of MDs, RNs, patient care coordinators, and case/disease managers

• An ability to understand overall managed care organization, business strategies, and financial metrics; strong interpersonal and communication skills are needed to effectively interact with employees and clients professionally

• Ability to lead and provide training and guidance to others

• Ability to work evenings and weekends as part of rotating on-call schedule

Your Knowledge and Experience

• Medical degree (M.D./D.O.)

• A minimum of 3 years of experience working for a Medical Group, IPA, or Health Plan making decisions for Medicare Advantage utilization is preferred but not required.

• A minimum of 5 years direct patient care experience post residency.

• Active recent hospital experience (within the past five years) is desirable. Strong clinical skills with prior experience in a primary care setting.

• A medical degree (MD or DO) with 5 or more years of clinical experience, preferably in a managed care setting with hospital experience, since a large part of this position involves inpatient con-current review. 

• 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 recognized specialty required (preferably Internal Medicine or Family Practice)

• 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
    
     

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.