The Appeals and Grievances Medical Director is responsible for clinical review and adjudication of appeals and grievances across various health plans, including PPO, HMO, and others.

They evaluate adverse determination cases, interpret medical policies, and communicate decisions to internal teams and regulatory bodies.

The role involves participating in team meetings, providing clinical and strategic input for organizational initiatives, and collaborating with regional and network management staff.

Qualifications include an active MD or DO license, board certification in an ABMS or AOBMS specialty, and at least 5 years of clinical practice experience with 2+ years in Quality Management.

Key skills include managed care proficiency, excellent communication, project management, data analysis, presentation abilities, and creative problem-solving.

This remote role offers a competitive compensation package, benefits, and opportunities for professional growth.