Appeals and Grievances Medical Director Reconsiderations - Remote

About the role

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

Responsibilities

• Conduct individual case reviews related to adverse determinations for medical services.
• Respond to Department of Insurance, Department of Managed Healthcare, and CMS inquiries.
• Collaborate with medical directors, regional teams, and network staff on access, quality, and coverage issues.
• Participate in team meetings focused on communication, process improvement, and staff development.
• Contribute to organizational committees, projects, and initiatives with clinical and strategic insights.

Requirements

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

Skills

• Excellent presentation and telephonic communication.
• Strong project management and problem-solving abilities.
• Team collaboration and interpersonal skills.

Benefits

• Remote work flexibility.
• Competitive compensation.
• Comprehensive benefits.
• Opportunities for professional growth.