Appeals Physician - Remote

About the role

The Appeals and Grievances Medical Director performs clinical review and adjudication of appeals and grievances for various health plan products. The role ensures compliance with regulatory requirements, interprets medical policies, and communicates decisions and benefit interpretations to medical directors, regional teams, and network management. The position involves active participation in team meetings, process improvements, and organizational committees.

Responsibilities

• Conduct clinical review and adjudication of appeals and grievances for health plan products.
• Ensure compliance with regulatory requirements and interpret medical policies.
• Communicate decisions and benefit interpretations to medical directors, regional teams, and network management.
• Participate in team meetings, process improvements, and organizational committees.

Requirements

• MD or DO with an active medical license.
• Board certification in an ABMS or AOBMS specialty (excluding Pediatrics).
• At least five years of clinical practice experience.

Qualifications

Preferred qualifications include:

• Experience in quality management.
• Proficiency in managed care.
• Strong communication and presentation skills.
• Project management and data analysis abilities.
• Team-building skills.

Benefits

• Competitive salary range.
• Comprehensive benefits package.
• Opportunities for professional growth.
• Remote work flexibility within the U.S.