Appeals and Grievances Medical Director - Remote

Position Overview

The Appeals and Grievances Medical Director is tasked with overseeing the assessment of medical appeals and grievances within a variety of health plan programs. This role ensures adherence to regulatory standards while delivering clinical expertise and strategic guidance.

Key Responsibilities

• Conduct thorough reviews of individual cases involving adverse medical service decisions.
• Address inquiries from regulatory bodies such as the Department of Insurance, Department of Managed Healthcare, and CMS.
• Work closely with fellow medical directors, network managers, and team members on issues related to benefits interpretation, accessibility, and quality assurance.
• Engage actively in team meetings, process optimization, personnel training, and participation in organizational committees.
• Provide clinical perspectives and contribute to various organizational initiatives and projects.

Qualifications and Experience

• Possession of an MD or DO degree with a current, unrestricted medical license and board certification in a specialty other than pediatrics.
• A minimum of five years of clinical practice experience and at least two years in Quality Management roles.
• Background in managed care along with strong communication, presentation, project management, data analysis, and problem-solving skills.
• Competence with computer systems, research methodologies, and excellent interpersonal skills; a collaborative approach with demonstrated leadership capabilities.