Medical Director

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversees clinical governance and oversight for the medical review program, encompassing appeals, rescission, and grievance panel processes.

• Executes thorough clinical reviews for first and second-level appeals, including complaints filed with the Department of Insurance (DOI).

• Assesses complex medical cases to ensure adherence to policy provisions, clinical guidelines, and regulatory standards.

• Utilizes expert clinical judgment in making high-risk or sensitive determinations.

• Applies independent clinical judgment to support coverage decisions, free from claims or financial bias.

• Ensures alignment and consistency across appeal results and internal review processes.

• Directs clinical evaluation and decision-making for rescission cases and member grievances.

• Guarantees the proper application of underwriting intent and policy interpretation during misrepresentation reviews.

• Collaborates with legal teams on complex or escalated cases.

• Works alongside legal to ensure compliance with relevant state and federal regulations governing adverse benefit determinations, grievance processes, and clinical review standards.

• Records clinical rationale supporting determinations in a format suitable for regulatory review, audits, and litigation.

• Recognizes opportunities to enhance upstream underwriting and risk selection practices.

• Aids in quality assurance and the consistency of TPA decision-making.

• Collaborates with product management and actuarial teams to inform product design and risk selection strategies.

• Identifies trends and provides clinical insights on emerging risks, market dynamics, and competitive positioning.

• Contributes to initiatives aimed at integrating AI and/or automation into medical review workflows.

• Proactively identifies and proposes opportunities to streamline processes and enhance efficiency.

• Works with stakeholders to maintain alignment on priorities, timelines, and expected outcomes.

⛳️ Requirements

• Bachelor's degree (4 years) is required.

• MD or DO degree is required.

• A minimum of 8 years of experience is required.

• An active and unrestricted medical license is required.

• Experience in health insurance is preferred.

• Proficiency in MS Word, PowerPoint, and Excel.

• Strong verbal and written communication skills.

• Capability to manage shifting priorities effectively.

• Proficient presentation skills, including the ability to convey complex medical risk information.

🏝️ Benefits

• Allstate offers a comprehensive technology setup that includes a laptop, monitors, headset, keyboard, and mouse.

• Employees who are eligible to work from home receive a monthly connectivity reimbursement to help cover internet expenses.

• Reliable internet is essential, with minimum speed requirements of 50 MB download and 5 MB upload.