Appeals and Grievances Medical Director Reconsiderations - Remote

About the role

Responsible for reviewing appeals related to medical services across various health plan products, ensuring compliance with regulatory responses, and providing clinical and strategic input.

Responsibilities

• Conduct individual case reviews for appeals and grievances involving benefit coverage and clinical criteria.
• Manage responses to regulatory agencies such as Department of Insurance, Department of Managed Healthcare, and CMS.
• Collaborate with medical directors, network staff, and team members on decision rationales, access, and quality issues.
• Participate in team meetings, organizational committees, and projects to improve processes and share program results.
• Contribute clinical expertise to organizational initiatives and problem-solving efforts.

Requirements

• MD or DO with active, unrestricted license and board certification in an ABMS or AOBMS specialty (excluding Pediatrics).
• Minimum 5 years of clinical practice and 2 years in Quality Management.
• Proficiency in managed care, computer skills, and data analysis.

Skills

• Excellent presentation, communication, project management, and interpersonal skills.
• Strong problem-solving and team-building abilities.

Benefits

• Remote work flexibility within the U.S.
• Competitive compensation.
• Comprehensive benefits.
• Commitment to health equity and diversity.

Candidates must pass a drug test and adhere to telecommuting policies.