Appeals and Grievances Medical Director Reconsiderations - Remote

About the role

Provide clinical review for appeals and grievances across various health plan products, addressing adverse determinations related to medical services, coverage, and clinical criteria.

Responsibilities

• Communicate with medical directors and network teams on benefit interpretations, access, quality, and network issues.
• Participate in team meetings for process improvement, training, and program outcomes.
• Contribute clinical and strategic insights to organizational committees and projects.

Requirements

• MD or DO with active license.
• Board-certified in an ABMS or AOBMS specialty (excluding Pediatrics).
• 5+ years of clinical practice.
• 2+ years in Quality Management.

Skills

• Proficient in managed care, computer skills, presentation, telephonic communication, project management, data analysis, problem-solving, and team collaboration.
• Familiar with current medical practices and policies.

Pay

Salary range from $248,500 to $373,000, including base pay and bonuses.

Benefits

• Comprehensive benefits.
• Incentives and retirement options.
• Remote work flexibility.
• Inclusive, performance-driven environment focused on healthcare improvement.