Corporate MD Grievance & Appeals
Core
Provide clinical interpretation and independent determinations regarding the appropriateness, necessity, and quality of healthcare services for grievance and appeal cases across Medicare, Medicaid, and Commercial products.
Role type
Senior clinical subject matter expert (Medical Director)
Builds
Clinical review decisions and member-centered care determinations
Domain
Healthcare / Managed Care / Insurance
Required skills
Medical interpretation, clinical judgment, regulatory compliance, managed care operations knowledge, complex case analysis, cross-functional collaboration
Preferred skills
Utilization management experience, patient/provider interaction, specific clinical specialties (Internal Medicine, Geriatrics, etc.)
Technologies
None stated
Responsibilities
Review medical records for appeals decisions, ensure compliance with medical review policies and regulations, act as clinical resource for home health and inpatient services, partner with teams to improve consistency and turnaround times, support after-hours coverage as needed
Seniority
Senior, hands-on IC