Corporate MD Grievance & Appeals

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The Corporate Medical Director relies on medical background and reviews of medical records for appeals decisions. The Corporate Medical Director works on problems of diverse scope and complexity ranging from moderate to substantial.

The Corporate Medical Director provides clinical interpretation and makes determinations regarding the appropriateness of services delivered by other healthcare professionals, in accordance with established review policies, procedures, and performance standards. The Corporate Medical Director exercises independent judgment in addressing complex issues related to job responsibilities and associated tasks, applying critical analysis to variable factors and determining the most appropriate course of action.

Provide medical interpretation and clinical judgment regarding the appropriateness, necessity, and quality of services rendered by other healthcare professionals.

Perform or oversee clinical reviews of grievance and appeal cases for assigned markets, member populations, or condition-specific areas.

Ensure all determinations are made in compliance with medical review policies, regulatory requirements, internal procedures, and performance standards.

Serve as a clinical subject matter expert for complex grievance and appeal matters involving Medicare, Medicaid, and Commercial products.

Make independent decisions on highly complex clinical issues, including cases with variable factors, incomplete information, or competing clinical considerations.

Act as a clinical resource for issues involving home health, rehabilitation, inpatient, outpatient, and transitional care services.

Ensure appeal and grievance reviews reflect knowledge of managed care operations, including Medicare, Medicaid, and Commercial line-of-business requirements.

Partner with cross-functional teams to improve consistency, turnaround times, compliance, and member-centered decision-making.

Contribute to initiatives focused on improving the member experience and reducing preventable escalations or dissatisfaction.

Provide expertise across relevant clinical specialties such as Internal Medicine, Family Practice, Geriatrics, and Hospital Medicine.

Support holidays and weekends as required based on business needs. After-hours coverage as required to maintain regulatory and operational review timelines.

Maintain awareness of emerging regulations, accreditation standards, and medical policy changes affecting grievance and appeal determinations.

MD or DO degree

Current, unrestricted licensure in at least one jurisdiction, with the ability and willingness to obtain additional unrestricted licenses, as needed, for states within the assigned region.

No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.

Board Certified in an approved ABMS Medical Specialty

Prompt professional communication skills written and verbally

5 years of established clinical experience post residency

Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

Medical utilization management experience in MA Grievances and Appeals

Working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.

Internal Medicine, Family Practice, Geriatrics, Hospitalist, Anesthesiology, Physical Medicine and Rehabilitation, Emergency Medicine, Neurology, and General Surgery clinical specialists