Appeals and Grievances Medical Director Reconsiderations

About the Role

Responsible for reviewing appeals and grievances related to various health plan products, ensuring compliance with regulatory agencies, and providing clinical and strategic input.

Responsibilities

• Perform individual case reviews for appeals and grievances, addressing adverse determinations and coverage issues.
• Respond to Department of Insurance, Department of Managed Healthcare, and CMS inquiries.
• Collaborate with medical directors, network staff, and teams to discuss appeal rationales, benefit interpretations, access, and quality concerns.
• Participate in team meetings focusing on communication, process improvements, staff training, and sharing program results.
• Contribute clinical and strategic insights to organizational committees and projects.

Requirements

• MD or DO with active, unrestricted license.
• Board Certified in an ABMS or AOBMS specialty (excluding pediatrics).
• Minimum of 5 years clinical practice and 2 years in Quality Management.

Skills

• Proficiency in managed care.
• Strong computer skills, presentation, and communication abilities.
• Experience in project management, data analysis, problem-solving, and teamwork.