Medical Director Appeals, Grievances & Disputes

About the role

Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system. The Medical Director of Appeals and Grievances (A&G) and Provider/Consumer Complaints and Dispute is responsible for leadership, operational execution, clinical and regulatory oversight, and enterprise governance of Kern Health System’s grievance, appeal, and State Fair Hearing functions across all product lines.

Responsibilities

• Reviews medical records or case files and writes a clear and impartial reconsideration or dispute resolution decision supporting the determination and documents the review.
• Conducts medical necessity evaluations with complete clinical documentation and follows evidence-based guidelines to ensure quality member care.
• Collaborates with grievance and appeals to staff to support clinical decisions and quickly identify, escalate, and resolve quality-of-care issues.
• Ensures consistency in documentation of clinical rationale, decision accuracy, and regulatory adherence across all clinical case types.
• Examines emerging patterns and works with network management to address challenges related to access, availability, operations, and quality.
• Actively participates in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program results.
• Provides medical interpretation and assesses the suitability of other healthcare professionals' services in accordance with review guidelines and performance standards.
• Adheres to company policies and procedures, in addition to federal and state regulations governing grievances and appeals.
• Promotes an environment of ongoing enhancement and innovation within the grievances and appeals department.
• Acts as a bridge between members and healthcare providers to ensure grievances and appeals are resolved promptly and appropriately.
• Stays informed about industry trends and best practices related to member satisfaction and grievances and appeals processes.
• Engages in continuous strategies to strengthen the infrastructure of the Appeals and Grievance department.
• Provides support to the Quality Improvement department through participation in targeted quality studies and evaluations.
• Establishes key performance indicators to track progress and enhance the Quality Improvement Department.
• Serves as chair of the Appeals and Grievance Committee and promotes best practices and regulatory compliance.
• Attends all regulatory audits as the primary representative of the appeals department.
• Guides the Appeals and Grievance Department through complex regulatory audits, consistently securing compliant results and implementing lasting remediation strategies.

Requirements

• A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization.
• Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).
• KHS reasonably expects to pay starting compensation for the position of Medical Director, Appeals, Grievances & Disputes in the range of $257,050 – $340,591.50 annually.

Qualifications

• MD or DO with an active, unrestricted license in California
• Board Certified in an ABMS or AOBMS specialty preferred
• 5 years minimum clinical practice experience
• 2 years minimum experience of grievance and appeals management at a Managed Care health plan or similar business model
• 2 years minimum Quality of Care Management experience
• Experience in Medicaid and Medicare managed care lines of business, with deep understanding of their operational, regulatory, and service requirements
• Experience navigating regulatory and accreditation requirements, with a strong track record of applying complex regulatory standards to grievance, appeal, and quality-of-care operations
• Experience improving operational accuracy, strengthening documentation quality, and ensuring consistent alignment with federal and state regulatory expectations
• Experience leading organizations through high-stakes regulatory audits, with a consistent record of achieving compliant outcomes and driving sustainable remediation

Skills

• Extensive experience working within delegated, plan-partner, or subcontracted network environments
• Demonstrated ability to oversee performance, ensure compliance, and manage complex accountability structures
• Ability to develop analytic dashboards and visualization tools (e.g., Power BI, Tableau)

Benefits

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.