Appeals Medical Director - Cardiology
Proforma Health · Wilmington, DE · 1 mo ago
Full-time
About the role
This role involves overseeing appeal reviews for physical health medical services to ensure appropriate, cost-effective care. The Medical Director may develop new policies, lead clinical programs, identify opportunities for improvement, and serve as a strategic advisor.
Responsibilities
- Support clinicians with timely responses and provide clinical guidance
- Conduct peer-to-peer reviews and interpret medical policies
- Develop new medical policies and lead clinical programs
- Identify opportunities for improvement in healthcare quality, outcomes, and efficiency
- Represent the organization externally and chair committees
- Drive initiatives to enhance healthcare delivery
Qualifications
- MD or DO with board certification from ABMS or AOA
- Active, unrestricted medical license
- Minimum of 10 years of clinical experience; 5 years for specific health organization roles
- Preferred: Board certification in Cardiology
- Preferred: Experience in Utilization Management or Appeals
Skills
- Strong clinical expertise and decision-making skills
- Ability to interpret policies and develop clinical programs
- Excellent communication, leadership, and strategic thinking abilities