Appeals Medical Director – Medicare

About the Role

The Appeals Medical Director reviews appeals related to physical health medical services, ensuring appropriate and cost-effective care. The role supports clinical operations, develops quality and cost improvement programs, and provides clinical consultation.

Responsibilities

• Conduct appeal reviews and support timely, consistent responses to members and providers.
• Provide guidance on clinical operational aspects of programs.
• Perform peer-to-peer clinical case reviews with providers.
• Interpret and develop medical policies and guidelines.
• Lead initiatives to improve healthcare quality, outcomes, and cost-efficiency.
• Serve as a resource and represent the organization externally when needed.
• Identify opportunities for clinical and operational innovation.

Requirements

• 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 Qualifications

• Experience in primary care, utilization management, or appeals.

Schedule

Flexible, mostly virtual work with in-person training. Position is located in select U.S. states.

Pay

Compensation ranges from $247,840 to $446,112.

Benefits

Comprehensive benefits package included.