California Licensed Radiologist

Job Summary

To ensure fair and evidence-based review of member appeals, the remote California Licensed Radiologist will conduct independent clinical reviews, collaborate with a team of healthcare professionals, and contribute to quality improvement initiatives in a full-time capacity.

Key responsibilities:

• Conduct independent clinical reviews of member appeals and grievances involving Medicare and Commercial health plans
• Evaluate appeals related to adverse coverage determinations for medical services using evidence-based medicine and regulatory requirements
• Collaborate with fellow Medical Directors on appeal determinations and participate in departmental meetings focused on quality improvement

Required qualifications:

• MD or DO degree with an active, unrestricted medical license
• Board Certification in an ABMS or AOBMS-recognized specialty
• Proven solid clinical judgment in a utilization management and appeals environment
• Experience applying evidence-based medicine in clinical decision-making