California Licensed Appeals Medical Director
Job Summary
To support ongoing clinical reviews, the remote California Licensed Appeals Medical Director will manage the adjudication of appeals and grievances cases for various health plan products, ensuring compliance with regulatory requirements and collaborating with medical directors on decision rationales.
Key responsibilities:
- Perform individual case reviews for appeals and grievances related to medical services and benefit coverage
- Respond to regulatory inquiries from the Department of Insurance, Department of Managed Healthcare, and CMS
- Participate in team meetings to enhance communication, process improvement, and staff training
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
- Familiarity with managed care practices
Complete Job Description
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