Appeals Physician - Remote

About the role

The Appeals and Grievances Medical Director is responsible for clinical review and adjudication of appeals and grievances related to various health plan products, ensuring compliance with regulatory agencies. They perform case reviews, communicate decision rationales, and collaborate with medical directors and network staff on access, quality, and coverage issues.

The role involves participating in team meetings, providing clinical and strategic input for organizational projects, and supporting process improvements in a mission-driven environment focused on improving healthcare quality, equity, and patient outcomes.

Responsibilities

• Perform clinical review and adjudication of appeals and grievances for health plan products
• Ensure compliance with regulatory agency requirements
• Communicate decision rationales to stakeholders
• Collaborate with medical directors and network staff on access, quality, and coverage issues
• Participate in team meetings and provide clinical and strategic input for organizational projects
• Support process improvements and initiatives

Qualifications

• MD or DO with an active medical license
• Board certification in a non-pediatric specialty
• At least five years of clinical practice experience

Skills

• Quality management and managed care proficiency
• Excellent written and verbal communication
• Project management and data analysis
• Strong presentation abilities
• Problem-solving and teamwork

Pay

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

Benefits

Comprehensive benefits package included.