Licensed Appeals Medical Director

Job Summary

To support ongoing clinical review and adjudication of appeals and grievances, the remote Licensed Appeals Medical Director will manage individual case reviews for various health plan products and communicate with medical directors regarding appeals decisions.

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 improve processes, provide feedback, and share program results

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