Medical Director, Appeals

This is a fully remote position, open to applicants in Arizona, +9 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 reduction, and medical quality enhancement initiatives.

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

• Support initiatives aimed at improving performance for capitated providers.

• Aid in establishing goals and policies to enhance the quality and cost-effectiveness of care and services.

• Offer medical expertise for quality improvement and utilization management programs that comply with regulatory, state, corporate, and accreditation standards.

• Assist with physician committees, including their structure, processes, and membership composition.

• Perform regular rounds for high-risk patients and work collaboratively with care management teams.

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

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

• Support physician education related to clinical issues and policies.

• Identify areas for utilization review and clinical quality improvement studies.

• Assess adverse utilization trends, unusual provider practice patterns, and the adequacy of benefits/payments.

• 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 payment.

• Foster provider-community alliances through medical management initiatives.

• Represent the business unit in public forums, state committees, and ad hoc committees as required.

⛳️ Requirements

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

• Actively engaged in practicing medicine.

• Board certified in a medical specialty recognized 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.

• Preferred experience in Utilization Management and familiarity with quality accreditation standards.

• Certification in Internal or Family Medicine is preferred.

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

• Preferred experience in treating or managing care for a culturally diverse population.

• May be required to work weekends and holidays to support business operations as necessary.

🏝️ Benefits

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off along with holidays.

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

• Competitive compensation.