Medical Director, Claims Review

Job Summary

Working remotely from anywhere in the U.S., the full-time Medical Director, Claims Review will manage clinical reviews, collaborate with healthcare providers, and ensure appropriate benefit determinations while focusing on quality improvement and cost-effectiveness in service delivery.

Key responsibilities

• Conduct coverage reviews based on individual member plan benefits and render coverage determinations
• Document clinical review findings and engage in peer-to-peer discussions with requesting providers
• Communicate and collaborate with network and non-network providers to ensure accurate benefit determinations

Required qualifications

• M.D. or D.O. degree
• Active unrestricted medical license with the ability to obtain additional state licenses
• Current board certification in Medicine through ABMS or AOA
• 5+ years of physician clinical practice experience post-residency
• Proven understanding of Evidence Based Medicine (EBM)