Licensed Appeals Medical Director

Job Summary

Working remotely from anywhere in the U.S., the full-time Licensed Appeals Medical Director will conduct clinical reviews and adjudications of appeals and grievances cases for various health plans, ensuring compliance with regulatory standards and collaborating with medical directors on decision rationales.

Key responsibilities:

• Perform individual case reviews for appeals and grievances related to medical services and benefit design
• Respond to regulatory inquiries from the Department of Insurance, Department of Managed Healthcare, and CMS
• Participate in team meetings to enhance communication, problem-solving, and process improvements

Required qualifications:

• MD or DO with an active, unrestricted license
• Board Certified in an ABMS or AOBMS specialty (excluding Pediatrics)
• 5+ years of clinical practice experience