Medical Director, Appeals

This is a fully remote position, open to applicants in Arizona, +8 more states.

📋 Description

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

• Offer medical leadership for utilization management, cost containment, and initiatives aimed at improving medical quality.

• Conduct medical reviews related to utilization assessments, quality assurance, and complex, controversial, experimental, or novel medical services.

• Perform regular rounds to evaluate and coordinate care for patients classified as high-risk.

• Collaborate with care management teams, clinical teams, network providers, appeals teams, and medical and pharmacy consultants.

• Assist in performance improvement initiatives targeting capitated providers.

• Help in setting goals and policies aimed at enhancing the quality and cost-effectiveness of care.

• Provide medical expertise for quality improvement and utilization management programs.

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

• Engage in provider network development and expansion into new markets.

• Support physician education concerning clinical matters and policies.

• Identify studies focused on utilization review and clinical quality improvement, while evaluating adverse utilization trends.

• Facilitate recommendations to providers to enhance utilization and healthcare quality.

• Review complex claims to assess medical necessity and appropriate payment decisions.

• Foster provider-community alliances through medical management initiatives.

• Represent the business unit in front of public, state, and ad hoc committees as necessary.

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy degree required.

• 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, free of restrictions, limitations, or sanctions from government programs.

• Experience in Utilization Management and familiarity with quality accreditation standards 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 may be required to support business operations.

🏝️ Benefits

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement assistance.

• Paid time off along with holidays.

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

• Competitive compensation.