Medical Director, Appeals

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

📋 Description

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

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

• Conduct medical reviews for utilization assessments, quality assurance, and intricate, contentious, or experimental medical services.

• Aid performance improvement efforts for capitated providers.

• Contribute to goals and policies designed to enhance the quality and cost-effectiveness of care and services.

• Provide medical expertise for quality enhancement and utilization management programs in line with regulatory, state, corporate, and accreditation standards.

• Assist with the structure, processes, and membership of physician committees.

• Carry out regular rounds to evaluate and coordinate care for high-risk patients.

• 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.

• Facilitate physician education on clinical matters and policies.

• Identify utilization review studies and assess adverse utilization trends, unusual provider practice patterns, and benefit/payment adequacy.

• Recognize clinical quality improvement studies aimed at reducing unwarranted variation and enhancing the quality and cost of care.

• Interact with physicians and providers to implement recommendations that improve utilization and the quality of healthcare.

• Review intricate, controversial, unusual, or new-service claims to ascertain medical necessity and appropriate payment.

• Build provider-community alliances through medical management initiatives.

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

⛳️ Requirements

• Medical Doctor or Doctor of Osteopathy degree required.

• Must be actively practicing 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 without any 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.

• 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 as needed.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase plans.

• Tuition reimbursement opportunities.

• Paid time off along with holidays.

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

• Additional forms of incentives may be included in total compensation.