California Licensed Appeals Medical Director

Job Summary

To support a growing healthcare organization, the remote California Licensed Appeals Medical Director will manage clinical reviews and adjudications of appeals and grievances for various health plan products while collaborating with medical directors and participating in organizational committees.

Key responsibilities:

• Conduct 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
• Engage in team meetings to enhance communication, problem-solving, and process improvement efforts

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 and current medical issues