Medical Director, Utilization Management - Concurrent Review
 Blue Shield of CA | |
 United States, California, San Diego | |
 May 16, 2025 | |
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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. Your Knowledge and Experience
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