Remote Medical Director, Appeals

Position Purpose

Aid the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. Provide medical leadership in utilization management, cost containment, and medical quality improvement activities. Perform medical review activities for utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.

Responsibilities

• Support effective implementation of performance improvement initiatives for capitated providers.
• Aid the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provide medical expertise in the operation of approved quality improvement and utilization management programs in compliance with regulatory, state, corporate, and accreditation requirements.
• Assist in the functioning of physician committees, including committee structure, processes, and membership.
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
• Collaborate with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
• Participate in provider network development and new market expansion as appropriate.
• Develop alliances with the provider community through the development and implementation of medical management programs.
• Represent the business unit before various publics and at appropriate state committees and other ad hoc committees.
• May be required to work weekends and holidays in support of business operations, as needed.

Requirements

• Medical Doctor or Doctor of Osteopathy.
• Utilization Management experience and knowledge of quality accreditation standards preferred.
• Course work in Health Administration, Health Financing, Insurance, and/or Personnel Management advantageous.
• Experience treating or managing care for a culturally diverse population preferred.
• Active Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.
• Certification in Internal or Family Medicine specialty, preferred.
• Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Qualifications

• Competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.
• Total compensation may also include additional forms of incentives.
• Benefits may be subject to program eligibility.

Skills

• Strong medical knowledge and leadership skills.
• Excellent communication and collaboration abilities.
• Ability to manage complex medical cases and make informed decisions.
• Knowledge of healthcare regulations and accreditation standards.

Benefits

• Comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.
• Total compensation may also include additional forms of incentives.
• Benefits may be subject to program eligibility.

Pay

$236,500.00 - $449,300.00 per year