State Licensed Appeals Medical Director

Job Summary

To support the clinical review process, the remote State Licensed Appeals Medical Director in Urology Specialty will manage appeals and grievances cases, perform individual case reviews, and communicate with medical directors regarding appeals decisions.

Key responsibilities

• Perform individual case reviews for appeals and grievances related to various health plan products
• Respond to regulatory inquiries from the Department of Insurance, Department of Managed Healthcare, and CMS
• Participate in team meetings and organizational committees to provide clinical input and improve processes

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 current medical issues and managed care practices