Responsible for the appeal reviews for physical health medical services
Ensure the appropriate and most cost-effective medical care is received
Develop and implement programs to improve quality, cost, and outcomes
Provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations
Identify cost of care opportunities
Supports clinicians to ensure timely and consistent responses to members and providers
Provides guidance for clinical operational aspects of a program
Conduct peer-to-peer clinical case reviews with attending physicians or other ordering providers
Serves as a resource and consultant to other areas of the company
May represent the company to external entities and/or serve on internal and/or external committees
May chair company committees
Interprets medical policies and clinical guidelines
May develop and propose new medical policies based on changes in healthcare
Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes
Identifies and develops opportunities for innovation to increase effectiveness and quality

Requires MD or DO and Board certification approved by one of the following certifying boards is required
Must possess an active unrestricted medical license to practice medicine or a health profession
Minimum of 10 years of clinical experience
For Health Solutions and Carelon organizations, minimum of 5 years of experience providing health care is required
Primary Care specialties preferred
Utilization Management or Appeals experience preferred

Medical Director – Medicare

About this role