Remote Medical Director, Appeals

Role: Clinical professional responsible for leading medical management, quality improvement, and credentialing functions within a health services team. Responsibilities Provide medical leadership for utilization management, cost containment, and quality initiatives. Perform medical reviews related to utilization, quality assurance, and complex or experimental services. Support performance improvement programs for capitated providers and assist in setting goals to enhance care quality and efficiency. Contribute to the operation of quality improvement and utilization programs in compliance with regulations and standards. Participate in physician committees, provider network development, and new market expansion. Conduct rounds for high-risk patient care, collaborate with clinical teams, and review complex cases and appeals. Develop physician education programs and identify clinical studies to reduce unwarranted practice variations. Review claims for complex or unusual services to determine medical necessity and appropriate payments. Build partnerships with providers through management programs and represent the organization in external committees. Qualifications & Skills Medical Doctor or Doctor of Osteopathy with active board certification in a recognized specialty. Utilization management experience and knowledge of accreditation standards preferred. Current unrestricted state medical license and active clinical practice. Relevant coursework in health administration, financing, insurance, or personnel management is advantageous. Experience with culturally diverse populations is preferred. #J-18808-Ljbffr Vetted Solutions