Role: The Appeals and Grievances Medical Director oversees clinical review and adjudication of appeals and grievances for various health plans.
Responsibilities: Conducts case reviews related to adverse determinations, manages regulatory responses, communicates clinical decision rationales, and collaborates with medical and network teams. Participates in team meetings, organizational committees, and strategic initiatives to improve processes and quality care.
Qualifications: MD or DO with unrestricted license, Board Certified in an ABMS or AOBMS specialty (excluding Pediatrics), and at least 5 years of clinical practice. Preferred skills include quality management experience, managed care proficiency, excellent communication, project management, data analysis, presentation skills, problem-solving, computer literacy, and team building.
Additional info: Remote work flexibility, competitive compensation, comprehensive benefits, and adherence to telecommuting policies. The role focuses on improving healthcare quality, equity, and responsiveness.