Overview Your Role
The Medical Director is a key member of the Medical Management team within the Healthcare Quality and Affordability business unit. This is a front-line utilization management position with core responsibilities in inpatient concurrent review, pre- and post-service utilization review, and collaboration with RN Case and disease managers. This director position will report to the Sr. Medical Director, Medical Management.
Responsibilities 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 require telephonic physician-to-physician discussions regarding current hospitalized patients. Therefore, the Medical Director must be comfortable in clinical conversations with Blue Shield providers.
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, and legal and regulatory requirements. Must be well-versed across medical areas, demonstrate rapid, accurate decision-making, and engage in care review and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency.
Participate on projects and committees as necessary.
Problem analysis and clinical decision-making, including independently formulating and implementing solutions.
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 translating detailed analytic analysis and complex materials into compelling communications.
Work in high-pressure situations while maintaining leadership and reasoning ability.
Strong collaboration skills to effectively work as a team that consists of MDs, RNs, patient care coordinators, and case/disease managers.
Understand overall managed care organization, business strategies, and financial metrics; strong interpersonal and communication skills are needed to interact professionally with employees and clients.
Lead and provide training and guidance to others.
Work evenings and weekends as part of a rotating on-call schedule.
Qualifications 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 concurrent 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 specialties 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 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.
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 regard 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.
Seniority level: Director
Employment type: Full-time
Job function: Health Care Provider
Industries: Insurance