Appeals and Grievances Medical Director Reconsiderations - Remote

About the Role

Responsible for reviewing appeals related to medical services, ensuring compliance with regulatory agencies, and collaborating with medical directors and network staff. The role emphasizes improving healthcare quality, equity, and patient outcomes in a collaborative environment.

Responsibilities

• Conduct individual case reviews for appeals and grievances across various health plan products.
• Address regulatory responses from agencies such as CMS and Department of Insurance.
• Communicate decision rationales and benefit interpretations to internal teams.
• Participate in team meetings focused on communication, process improvement, and training.
• 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).
• At least 5 years of clinical practice and 2 years of Quality Management experience.
• Proficiency in managed care.
• Strong communication, presentation, project management, data analysis, and problem-solving skills.
• Ability to work remotely following company policies.

Benefits

• Competitive compensation.
• Comprehensive benefits.
• Opportunities for professional growth.