Appeals and Grievances Medical Director Reconsiderations - Remote

About the Role

This position specializes in reviewing individual cases related to medical services and coverage appeals across various health plan products, ensuring compliance and providing clinical insights.

Responsibilities

• Perform case reviews for appeals and grievances, ensuring compliance with clinical criteria and regulatory requirements.
• Communicate appeal decisions and benefit interpretations with medical directors, regional teams, and network management.
• Participate in team meetings focused on communication, process improvement, training, and program results sharing.
• 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 5 years of clinical practice and 2 years in Quality Management.

Skills

• Proficient in managed care, data analysis, project management, and communication.
• Strong team player with problem-solving and interpersonal abilities.

Benefits

• Remote work flexibility.
• Opportunities for professional growth.
• Comprehensive benefits package.