Job Description

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. BCBSAZ offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

this role is a hybrid role and does require some time in the office

  • Direct, lead and provide professional oversight for medical management activities related to utilization management, peer clinical reviews, case management, disease management, and quality management activities. Support collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals and to ensure that medical policies, procedures and the activities/actions of the division on behalf of the corporation are consistent with the standards of good medical practice in the community.


Required Work Experience
  • 5 years of experience in a clinical setting
  • 5 years of experience in physician leadership role, including quality review, utilization review and other managed care functions
  • Utilization Mgmt experience to include Medicare and/or FEP

Required Education

  • Medical Degree

Required Licenses

  • Active, current, and unrestricted license to practice medicine in the State of Arizona  (a state in the United States).

Required Certifications

  • Board Certification


Preferred Work Experience
  • 5 years of experience in a primary care field

Preferred Education

  • N/A
Preferred Licenses
  • N/A
Preferred Certifications
  • N/A


  • Provide direction, support and medical expertise and oversight to areas within the Health Services Division such including utilization management, peer clinical review, quality management, case management, medical claims review, medical risk assessment, and pharmacy management. Specific activities include outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, precertification, medical underwriting, medical claims reconsideration and retrospective review.
  • Provide consultative services throughout the corporation, including for the Marketing, Sales, Legal, Actuarial, Network Management, Internal Audit, Finance, and Claims Divisions.
  • Communicate with customers regarding their difficult and costly cases, including recommendations and showing the impact of BCBSAZ interventions.
  • Provide peer clinical review activities and conversations as clinically appropriate including when requested for pre-service medical necessity denials.
  • Seek to improve department/division efficiency through effective use of information system tools and processes to reduce healthcare costs, increase quality of care and service, and reduce administrative expense.
  • Participate in the development of new products and benefit design.
  • Develop, review, and implement medical policies and other medical decision making policies or procedures
  • Represent BCBSAZ at professional organizations and acts as liaison with individual health care professionals and supports collaborative relationships with physicians and hospitals.
  • Provide professional oversight for the various clinical peer committees including, but not limited to, the Clinical Quality Improvement Committee, Credentialing Committee, Medical Directors Committee, Professional Committee, and Medical Management Committee.
  • Participate in medical management strategic planning in evaluating utilization, quality, national and local trends and identifies interventions to optimize the utilization of resources and the delivery of high quality health care services.
  • Participate in the appeals and grievance processes to assure timely and accurate responses to members and providers
  • Provide written information to members and providers through letters and articles in member and provider newsletters and other publications.
  • Work to ensure productive relationships with all customers, employers, members, and providers to ensure members receive the appropriate health care in the most appropriate setting with the best value in health care.
  • Provide leadership to staff and other professionals through clinical excellence, professional behavior and innovative thinking.


  • Oversee day-to-day departmental administration by coaching and motivating managerial staff and departmental personnel to make maximum use of experience and skills.
  • Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.
  • Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
  • Maintain effective working relationships to ensure teamwork in achieving corporate goals.
  • Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve BCBSAZ goals and ensure future success.
  • Coordinate activities between multiple divisions to achieve desired results.
  • Volunteer within the community to help BCBSAZ give back to community charitable efforts.
  • The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
  • Performs all other duties as assigned.



Required Job Skills

  •  Strong written and verbal communications.
  • Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones.
  • Intermediate skill in word processing, spreadsheet and database software.
  • Intermediate PC proficiency.

Required Professional Competencies

  • Excellent management skills as they relate to clerical and professional staff
  • Interpersonal skills that allow for harmonious relationships with providers, members and coworkers

Required Leadership Experience and Competencies

  • N/A

Our Commitment

BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona.  For more information on our company, see  If interested in this position, please apply.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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