Corporate Medical Director, Grievance and Appeals

About the role

Corporate-level reviews span Medicare, Medicaid and Commercial lines, with decisions that must hold up against regulation and internal policy.

At a glance

What you will do

• Review or oversee clinical case files for grievances and appeals across assigned markets and member groups
• Judge whether care delivered by other clinicians was suitable, needed and of good quality
• Keep every determination inside medical policy, regulatory rules and performance standards
• Act as the clinical expert on hard cases, including ones with gaps or conflicting evidence
• Advise on home health, rehab, inpatient, outpatient and transitional care questions
• Work with other teams to improve consistency, turnaround and the member experience

What they look for

• MD or DO degree
• Active unrestricted licence in one jurisdiction, with willingness to get licensed elsewhere as needed
• Board certification in an ABMS specialty
• At least five years of clinical practice after residency
• Familiarity with managed care, including Medicare, Medicaid or Commercial products
• Clear written and spoken communication

Nice to have

• Utilisation management experience in Medicare Advantage grievances and appeals
• Background working with insurers, hospitals and other providers