California Licensed Appeals Medical Director

Job Summary

To support the ongoing clinical review and adjudication of appeals and grievances cases, the remote California Licensed Appeals Medical Director will manage individual case reviews for various health plan products, communicate with medical directors regarding appeals decisions, and actively participate in team meetings focused on process improvement.

Key responsibilities

• Perform individual case reviews for appeals and grievances related to medical services and benefit design
• Communicate with medical directors and network management staff regarding access and quality issues
• Provide clinical and strategic input in organizational committees and projects

Required qualifications

• MD or DO with an active, unrestricted license
• Board Certified in an ABMS or AOBMS specialty
• 5+ years of clinical practice experience
• 2+ years of Quality Management experience
• Intermediate proficiency with managed care