responsible for the appeal reviews for physical health medical services, to ensure the appropriate and most cost-effective medical care is received.
May be responsible for developing and implementing programs to improve quality, cost, and outcomes.
May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations.
May 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.
May conduct peer-to-peer clinical case reviews with attending physicians or other ordering providers to discuss review determinations.
Serves as a resource and consultant for other areas of the company.
May be required to 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, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
Must possess an active unrestricted medical license to practice medicine or a health profession.
Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required.
Additional experience may be required by State contracts or regulations if the Medical Director is filling a role required by a State agency.
Board certification in Internal Medicine strongly preferred.
Utilization Management or Appeals experience preferred.

Appeals Medical Director – Internal Medicine

About this role