What are the responsibilities and job description for the Appeals and Grievances Medical Director Reconsiderations - Remote position at Black Women's Mental Health Institute?
Role: Medical Director specializing in Appeals and Grievances, responsible for reviewing individual cases related to medical services and coverage appeals across various health plan products.
Key Responsibilities
Key Responsibilities
- Perform case reviews for appeals and grievances, ensuring compliance with clinical criteria and regulatory requirements.
- Communicate appeal decisions and benefit interpretations with medical directors, regional teams, and network management.
- Participate in team meetings focused on communication, process improvement, training, and program results sharing.
- Contribute clinical and strategic insights to organizational committees and projects.
- MD or DO with active, unrestricted license.
- Board Certified in an ABMS or AOBMS specialty (excluding Pediatrics).
- Minimum 5 years of clinical practice and 2 years in Quality Management.
- Proficient in managed care, data analysis, project management, and communication skills.
- Strong team player with problem-solving and interpersonal abilities.