Medical Director - Medicare Appeals
Core
Lead Medicare Part C appeals for providers and members, providing direct support to appeal nurses and managing the Second Look Review (SLR) process.
Role type
Senior Medical Director (Medicare Appeals)
Builds
Efficient and clinically consistent Medicare appeals processes and utilization management strategies.
Domain
US Healthcare Insurance / Medicare Compliance
Required skills
Medicare policy expertise, Clinical practice experience, Utilization management, Second Look Review process management, After-hours coverage management, Team supervision, Subject matter expertise development, Policy education, Process improvement
Preferred skills
Medical Management experience, Medicare Complaints/Grievance/Appeals experience, Health Plan experience
Technologies
None stated
Responsibilities
Direct daily work on Part C appeals (provider and member/nonparticipating), Provide direct support to appeal nurses, Supervise and participate in Second Look Review (SLR) process, Provide after hours and weekend coverage, Monitor and track IRE, Collaborate with Medicare Quality and Compliance, Develop subject matter expertise on Medicare policy, Provide ongoing education to staff, Participate in initiatives to improve team efficiency and clinical consistency
Seniority
Senior, hands-on IC with leadership responsibilities