State Licensed Appeals Medical Director

Job Summary

To support the ongoing clinical review and adjudication of appeals and grievances cases, the full-time State Licensed Appeals Medical Director in Otolaryngology (ENT) will work remotely, performing case reviews for various health plans and communicating with medical directors regarding appeals decisions and quality issues.

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 provide feedback, problem-solving, and process improvement initiatives

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 practices