California Licensed Appeals Medical Director
Job Summary
To support the clinical review process, the remote California Licensed Appeals Medical Director will manage the adjudication of appeals and grievances cases, ensuring compliance with regulatory standards while collaborating with medical directors and staff across various health plans.
Key responsibilities
- Perform individual case reviews for appeals and grievances related to medical services and coverage determinations
- Communicate with medical directors regarding appeals decision rationales and benefit interpretations
- Actively participate in team meetings focused on process improvement, staff training, and sharing program results
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 current medical issues and practices
Complete Job Description
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