Medical Director, Arbitrations and Utilization Management (Part Time)

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, Arbitrations and UM MD Float is reporting to Sr. Medical Director, Arbitration/SIU/Mandates/Specialty Director Oversight. In this role, you will provide clinical review and support for provider arbitrations across Commercial and Medicare lines of business and provide flexible UM Medical Director coverage based on operational needs.

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.

This is a part-time position with a 0.6 FTE schedule

Your Work

In this role, you will:

Serve as Medical Director for the provider arbitration process.

Review clinical records and provide clinical support for provider arbitrations across Commercial and Medicare lines of business.

Partner with the Blue Shield Arbitration and Legal teams to prepare clinical analyses and provide testimony in arbitration proceedings.

Provide backup coverage for the Sr. Medical Director based on operational and coverage needs, including but not limited to SIU, mandates and Specialty Director Oversight

Provide UM Medical Director float coverage across Commercial and Medicare lines of business based on operational demand and coverage needs, including passing IRRs.

Perform timely clinical review and determinations for pre-service, concurrent, and retrospective utilization management cases, as assigned.

Apply benefit language, medical policies, and nationally recognized evidence-based medical necessity criteria consistently and document clear clinical rationale.

Conduct peer-to-peer discussions and provide clinical consultation on complex or escalated cases, as assigned.

Support continuity of UM operations during vacancies, leaves, workload surges, and other temporary coverage needs.

Meet applicable quality, timeliness, productivity, documentation, and regulatory requirements for assigned work.

Identify clinical or operational trends and collaborate with partners on opportunities to improve consistency, quality, and member experience.

Serve as a clinical, regulatory, and quality improvement resource and clinical thought leader within the organization.

Support the Sr. Medical Director, Arbitration/SIU/Mandates/Specialty Director Oversight, and Medical Management leaders in strategic and operational initiatives by providing clinical expertise and implementation support.

Collaborate with clinical and operational teams in the implementation and operation of assigned initiatives.

Understand and abide by all departmental policies and procedures, as well as the organization’s Standards of Conduct and Corporate Compliance Program.

Attend mandatory Corporate Compliance Program education sessions, including the annual Standards of Conduct class, as required for this position.

Participate actively in assigned committees and workgroups.

Abide by all applicable state and federal laws and regulations.

Perform all other duties as assigned.

Your Knowledge and Experience

Medical degree (M.D. or D.O.) required.

Completed residency in an adult-based primary care specialty (for example, internal medicine or family medicine) or another specialty relevant to the assigned clinical work.

Active, unrestricted California medical license required.

Board certification in an ABMS-recognized specialty required (Internal Medicine preferred).

Minimum of 5 years of direct patient care experience after residency.

Demonstrated proficiency in at least 3 of the following: utilization management, Medicare, NCQA/URAC or quality programs, medical policies and procedures, provider arbitration or litigation support, appeals and grievances, and case management or population health.

Health plan, utilization management, or related medical leadership experience is preferred

Knowledge of and skill in applying nationally recognized evidence-based medical necessity criteria, such as 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 analyses 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.

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.