Appeals Medical Director – Medicare

About the Role

The Appeals Medical Director – Medicare reviews appeals related to physical health medical services, ensuring the delivery of appropriate and cost-effective care. This role supports clinical operations, provides guidance, conducts peer-to-peer reviews, and develops programs to improve quality, outcomes, and costs. The director may also represent the organization externally, chair committees, interpret policies, and lead initiatives for innovation and improved healthcare efficiency.

Responsibilities

• Conduct appeal reviews and support timely responses to members and providers.
• Provide clinical consultation and guidance on operational aspects.
• Lead and implement clinical and non-clinical activities impacting healthcare quality, cost, and outcomes.
• Develop and propose medical policies based on healthcare changes.
• Identify opportunities for innovation to enhance effectiveness and quality.
• Serve as a resource and strategic advisor, representing the organization externally as needed.

Requirements

• MD or DO with Board certification (ABMS or AOA).
• Active, unrestricted medical license.
• Minimum of 10 years of clinical experience; 5 years for certain health organization roles.
• Preferred: Primary care specialties, utilization management, or appeals experience.

Benefits

• Comprehensive benefits package.
• Incentives and 401k contributions.

Pay

Salary ranges from $247,840 to $446,112, based on location and experience.

Schedule

Flexible, primarily virtual work with in-person training.