Appeals Physician - Remote

About the role

The Appeals and Grievances Medical Director is responsible for clinical review and adjudication of appeals and grievances across various health plan products, ensuring compliance with regulatory bodies. They perform case reviews related to adverse medical service determinations, communicate clinical rationale and benefit interpretations to internal teams, and participate in meetings focused on process improvement and staff development.

Responsibilities

• Conduct clinical reviews and adjudicate appeals and grievances for health plan products.
• Perform case reviews related to adverse medical service determinations.
• Communicate clinical rationale and benefit interpretations to internal teams.
• Participate in meetings focused on process improvement and staff development.
• Support organizational initiatives aimed at improving healthcare quality and access.
• Manage regulatory response and ensure compliance with regulatory bodies.

Qualifications

• MD or DO with an active, unrestricted license.
• Board certification in a non-pediatric specialty.
• At least 5 years of clinical practice experience.

Skills

• Quality management and managed care proficiency.
• Excellent communication and project management abilities.
• Data analysis and problem-solving skills.
• Team collaboration and clinical decision-making.