Medical Director

Role Overview

• Provides clinical oversight and governance for the medical review program, including appeals, rescission, and grievance panel processes
• Conducts comprehensive clinical reviews for first and second-level appeals, including Department of Insurance (DOI) complaints
• Evaluates complex medical cases to ensure consistency with policy provisions, clinical guidelines, and regulatory requirements
• Provides expert clinical judgment in high-risk or sensitive determinations
• Provides independent clinical judgement in support of coverage determinations, free from claims or financial influence
• Supports alignment and consistency across appeal outcomes and internal review processes
• Leads clinical evaluation and decision-making for rescission cases and member grievances
• Ensures appropriate application of underwriting intent and policy interpretation in misrepresentation reviews
• Partners with legal on complex or escalated cases
• Partners with legal to ensure compliance with applicable state and federal requirements governing adverse benefit determinations, grievance processes, and clinical review standards
• Documents clinical rationale supporting determinations in a manner suitable for regulatory review, audits and litigation
• Identifies opportunities to improve upstream underwriting and risk selection practices
• Supports quality assurance and consistency of TPA decision-making
• Partners with product management and actuarial teams to inform product design and risk selection strategies
• Identifies trends and provides clinical insight on emerging risks, market trends, and competitive positioning
• Contributes to and helps advance initiatives to integrate AI and/or automation into medical review workflows
• Proactively identifies and raises opportunities to streamline processes and improve efficiency
• Partners with stakeholders to help maintain alignment on priorities, timelines, and expected outcomes

Requirements

• 4 year Bachelors Degree (Required)
• MD or DO (Required)
• 8 or more years of experience (Required)
• Active and unrestricted license to practice medicine (Required)
• Experience working with health insurance preferred
• MS Word, PowerPoint and Excel spreadsheet skills
• Effective communication skills, verbal and written
• Ability to handle shifting priorities
• Effective presentation skills including the ability to present complex medical risk information.

Benefits

• Allstate provides a comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse.
• Employees eligible to work from home also receive a monthly connectivity reimbursement to help offset internet costs.
• Reliable internet is required, with minimum speeds of 50 MB download and 5 MB upload.