Appeals Medical Director – Medicare
Core
Lead clinical reviews for Medicare appeals to ensure appropriate and cost-effective medical care, serving as a strategic advisor to clinical operations.
Role type
Senior IC medical director (appeals/utilization management)
Builds
Clinical decision support for Medicare members and providers
Domain
US Healthcare / Medicare Appeals
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical diagnosis and treatment planning, Clinical policy interpretation, Peer-to-peer case review, Program development for quality and cost, Strategic clinical advising, Regulatory compliance
Preferred skills
Primary care specialty, Utilization management experience, Appeals process experience
Technologies
Electronic health records, Clinical decision support systems
Responsibilities
Conduct peer-to-peer clinical case reviews with ordering providers, Interpret medical policies and clinical guidelines, Develop and propose new medical policies, Lead clinical activities impacting healthcare quality and cost, Provide clinical consultation to enhance operations, Represent the company to external entities
Seniority
Director, hands-on IC with strategic oversight