Medical Director, Appeals

This is a fully remote position, open to applicants in Arizona, +4 more states.

📋 Description

• Collaborate with the Chief Medical Director to oversee and coordinate medical management, quality enhancement, and credentialing processes.

• Provide medical leadership in areas such as utilization management, cost efficiency, and initiatives for improving medical quality.

• Conduct medical review tasks related to utilization review, quality assurance, and the evaluation of complex, controversial, or experimental medical services.

• Facilitate the effective execution of performance improvement initiatives for capitated providers.

• Assist the Chief Medical Director in strategizing and setting objectives and policies aimed at enhancing the quality and cost-effectiveness of care.

• Offer medical expertise in the operation of sanctioned quality improvement and utilization management programs, adhering to regulatory, state, corporate, and accreditation standards.

• Aid the Chief Medical Director in the operation of physician committees.

• Work collaboratively with clinical teams, network providers, appeals teams, and consultants to review complex cases.

• Engage in the development of provider networks and expansion into new markets.

• Help in the creation and execution of physician education regarding clinical matters and policies.

• Identify utilization review studies and analyze adverse trends in the use of medical services.

• Communicate with physicians and other providers to support the implementation of recommendations for enhancing utilization and healthcare quality.

• Assess claims involving complex, controversial, or unusual services to ascertain medical necessity and appropriate reimbursement.

• Build partnerships with the provider community through medical management programs.

• Represent the business unit to various stakeholders both locally and nationally regarding medical philosophies and policies.

⛳️ Requirements

• Medical Doctor (MD) or Doctor of Osteopathy (DO).

• Experience in Utilization Management and familiarity with quality accreditation standards is preferred.

• Actively engaged in practicing medicine.

• Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management is beneficial.

• Experience in treating or managing healthcare for culturally diverse populations is preferred.

• Active Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.

• Certification in Internal or Family Medicine specialty is preferred.

• Current state license as an MD or DO without any restrictions, limitations, or sanctions from government programs.

🏝️ Benefits

• Competitive compensation.

• Health insurance coverage.

• 401K and stock purchase plans.

• Tuition reimbursement opportunities.

• Paid time off along with holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.