Appeals and Grievances Medical Director Reconsiderations

About the role

Provide clinical leadership in reviewing appeals and grievances across various health plan products, ensuring adherence to medical policies and regulatory requirements. Engage in communication with medical directors, regional teams, and network staff to address access, quality, and coverage issues. Participate in team meetings, offering clinical and strategic insights for process improvements, staff training, and organizational projects. Contribute to organizational committees and initiatives, promoting a collaborative and innovative healthcare environment.

Responsibilities

• Conduct case reviews for appeals and grievances
• Respond to regulatory inquiries
• Collaborate with medical and network teams
• Provide input on clinical and organizational strategies

Requirements

• MD or DO with an active, unrestricted license
• Board Certified in an ABMS or AOBMS specialty (excluding pediatrics)
• Minimum 5 years of clinical practice
• Minimum 2 years in Quality Management
• Proficiency in managed care
• Strong communication and presentation skills
• Project management experience
• Data analysis and problem-solving abilities
• Excellent interpersonal skills
• Basic computer literacy

Benefits

• Competitive compensation
• Comprehensive benefits

This is a remote role offering a flexible work environment.