What are the responsibilities and job description for the Appeals M.D. - Oncologist Required - Remote position at Fairview Hospital / Cleveland Clinic?
Appeals And Grievances Medical Director
Role: Responsible for clinical review and adjudication of appeals and grievances across various health plan products, ensuring compliance with regulatory bodies and providing benefit interpretations.
Key Responsibilities
Role: Responsible for clinical review and adjudication of appeals and grievances across various health plan products, ensuring compliance with regulatory bodies and providing benefit interpretations.
Key Responsibilities
- Perform individual case reviews related to adverse medical service determinations.
- Communicate decision rationales with medical directors and network management teams.
- Participate in team meetings, organizational committees, and projects to improve processes and share program results.
- Provide clinical and strategic input for organizational initiatives.
- MD or DO with active, unrestricted license and board certification in an ABMS or AOBMS specialty.
- Minimum of 5 years clinical practice and 2 years in Quality Management.
- Proficiency in managed care, data analysis, project management, and communication skills.
- Experience with regulatory responses and current medical practices is preferred.