Medical Director, Appeals

This is a fully remote position, open to applicants in Arizona, +5 more states.

📋 Description

• Assist the Chief Medical Director in overseeing and coordinating medical management, quality enhancement, and credentialing activities.

• Provide medical leadership for utilization management, cost control, and medical quality improvement initiatives.

• Conduct utilization reviews, ensure quality assurance, and perform medical evaluations of complex, controversial, or experimental services.

• Support the execution of performance improvement initiatives for capitated providers.

• Assist with goals and policies related to quality and cost-effectiveness.

• Offer medical expertise for quality enhancement and utilization management programs.

• Aid in the structure, processes, and membership of physician committees.

• Conduct rounds for high-risk patients and coordinate care with care management teams.

• Collaborate with clinical teams, network providers, appeals teams, and medical and pharmacy consultants on intricate cases and medical necessity appeals.

• Engage in provider network development and new market expansion efforts.

• Facilitate physician education regarding clinical issues and policies.

• Identify studies for utilization review, adverse trends in utilization, unusual provider practice patterns, and benefit/payment concerns.

• Recognize clinical quality improvement studies aimed at decreasing unwarranted variation and enhancing care quality and cost.

• Interact with physicians and providers to implement recommendations that enhance utilization and healthcare quality.

• Review complex, controversial, unusual, or new-service claims for medical necessity and appropriate payments.

• Build provider-community alliances through medical management initiatives.

• Represent the business unit on medical philosophy, policies, state committees, and other committees as necessary.

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy degree.

• Actively engaged in the practice of medicine.

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

• Current state license as an MD or DO with no restrictions, limitations, or sanctions from government programs.

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

• Certification in Internal or Family Medicine is preferred.

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

• Experience in treating or managing care for a culturally diverse population is preferred.

• Availability to work weekends and holidays as needed may be required.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off plus holidays.

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

• Additional incentives may be part of the total compensation package.

• Equal opportunity employer with a commitment to diversity.