Appeals and Grievances Medical Director Reconsiderations - Remote

About the Role

Provide clinical oversight by reviewing appeals and grievances across various health plan products, ensuring adherence to benefit design, coverage policies, and clinical criteria. Communicate with medical directors and network staff regarding benefit interpretations, access, and quality issues. Participate in team meetings focused on communication, process improvement, and staff development, while offering clinical and strategic input for organizational initiatives.

Responsibilities

• Conduct case reviews for appeals and grievances
• Respond to regulatory agencies
• Collaborate with medical and network teams
• Contribute to organizational committees and projects

Requirements

• MD or DO with active, unrestricted license
• Board certified in an ABMS or AOBMS specialty (excluding pediatrics)
• 5+ years clinical practice experience
• 2+ years in Quality Management

Skills

• Proficiency in managed care, data analysis, project management, and communication
• Strong presentation, interpersonal, and problem-solving skills
• Basic computer literacy and research skills