REMOTE - Medical Director - R12971
Core
Perform medical necessity reviews and adjudicate clinical appeals to ensure compliant, timely decision-making for healthcare coverage.
Role type
Senior Medical Director (Clinical Appeals)
Builds
Clinical appeals adjudication decisions and standardized clinical guidelines
Domain
Healthcare / Managed Care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical decision making, Healthcare policy knowledge, Appeals processing, Medical expertise, Outcomes improvement, Policy adherence, Medical necessity criteria evaluation, Clinical guidelines development, Stakeholder liaison, Regulatory compliance
Preferred skills
Managed care medical review experience, Business Administration knowledge
Technologies
MCG Certification, State licensure systems
Responsibilities
Review and determine complex clinical appeals based on medical guidelines and regulations, Provide clinical expertise on medical necessity and appropriateness of care, Collaborate with legal, compliance, and provider relations teams, Support development and implementation of clinical guidelines and protocols, Participate in quality assurance initiatives for the appeals process, Maintain state licensure and board certification status
Seniority
Senior, hands-on IC