Medical Director Grievances & Appeals
Core
Provide clinical interpretation and independent medical decisions on the appropriateness of healthcare services for complex appeal and grievance cases.
Role type
Senior Medical Director (Grievances & Appeals)
Builds
Defensible medical determinations for managed care appeals and grievances
Domain
US Healthcare Insurance / Managed Care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical judgment, evidence-based guideline application, Medicare/Medicaid regulation knowledge, quality improvement analysis, team leadership, HIPAA compliance
Preferred skills
Medical management experience, patient interaction, Internal Medicine/Family Practice/Geriatrics/Hospitalist specialization
Technologies
None stated
Responsibilities
Provide clinical interpretation and determinations on medical appropriateness of services; Make independent, timely, and defensible medical decisions on complex appeal cases; Collaborate with cross-functional teams to resolve grievances and appeals; Participate in quality improvement initiatives identifying trends; Serve as a clinical resource for grievance and appeals staff; Maintain current knowledge of Medicare regulations and managed care requirements; Participate in internal and external audits and respond to regulatory inquiries
Seniority
Senior, hands-on IC with leadership responsibilities