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 responses, and providing clinical and strategic input.

Responsibilities

• Perform individual case reviews related to adverse medical service determinations.
• Respond to Department of Insurance, Department of Managed Healthcare, and CMS inquiries.
• Collaborate with medical directors, network management, and team members on benefit interpretations, access, and quality issues.
• Participate in team meetings, process improvements, staff training, and organizational committees.
• Contribute clinical insights to organizational projects and initiatives.

Requirements

• MD or DO with active, unrestricted license and board certification in a non-pediatric specialty.
• Minimum of 5 years clinical practice and 2 years in Quality Management.
• Experience with managed care.

Skills

• Excellent communication and presentation skills.
• Strong project management, data analysis, and problem-solving skills.
• Proficiency in computer and research skills.
• Strong interpersonal skills; team-oriented with leadership abilities.