Appeals Physician - Remote

About the role

The Appeals and Grievances Medical Director is responsible for clinical review and adjudication of appeals and grievances for various health plans, ensuring compliance with regulatory standards and providing benefit interpretations.

They perform case reviews related to adverse determinations, communicate decision rationales with medical directors and network staff, and contribute to team meetings focused on process improvement and training.

Responsibilities

• Conduct clinical review and adjudication of appeals and grievances for health plans
• Ensure compliance with regulatory standards
• Provide benefit interpretations
• Perform case reviews related to adverse determinations
• Communicate decision rationales with medical directors and network staff
• Contribute to team meetings focused on process improvement and training

Requirements

• MD or DO with an active medical license
• Board certification in an ABMS or AOBMS specialty (excluding pediatrics)
• At least 5+ years of clinical practice experience

Qualifications

Preferred qualifications include:

• Experience in quality management
• Experience in managed care
• Strong communication skills
• Project management experience
• Data analysis skills
• Presentation skills

Skills

• Clinical expertise
• Communication
• Problem-solving
• Teamwork
• Adherence to telecommuting policies

Pay

Compensation ranges from $248,500 to $373,000.

Benefits

Comprehensive benefits package included.