Provides clinical oversight for health insurance medical management, with primary responsibility for appeals, rescissions, grievances, DOI complaints, and complex coverage determinations. This role also supports underwriting and policy interpretation, quality review, and process improvements across medical review workflows. The physician partners closely with legal, compliance, product, actuarial, and operational teams, with some work focused on AI-enabled modernization and remote collaboration.
Key Responsibilities
- Provide clinical oversight and governance for appeals, rescission, and grievance review processes.
- Conduct first- and second-level clinical reviews, including DOI complaints and complex case determinations.
- Evaluate medical cases for consistency with policy provisions, clinical guidelines, and regulatory requirements.
- Document clinical rationale for determinations to support audits, regulatory review, and litigation.
- Partner with legal and compliance teams on escalated cases, regulatory matters, and interpretation of state and federal requirements.
- Support underwriting intent, misrepresentation reviews, and upstream risk selection improvements.
- Collaborate with product, actuarial, and operational teams on product strategy, quality assurance, and process consistency.
- Contribute to AI, automation, and workflow improvements within medical review operations.
Required
- MD or DO degree from an accredited institution.
- Active, unrestricted U.S. medical license.
- Current board certification in an ABMS-recognized specialty.
- Completion of an ACGME-accredited residency program and any applicable fellowship training.
- At least 5 years of direct clinical experience after residency or fellowship.
- Experience applying clinical judgment in complex medical, regulatory, or insurance-related settings.
Preferred
- Experience in health insurance, managed care, payer, or health plan environments.
- Experience with appeals, grievances, utilization management, rescissions, or medical director functions.
- Experience partnering with legal, compliance, underwriting, product, actuarial, or operational teams.
- Experience leading clinical process improvements, quality initiatives, or technology-enabled transformation efforts.
- Experience advising executive leadership on medical and strategic business decisions.
Benefits & Perks
- Remote work with occasional commuting or travel for connection opportunities.
- Technology setup provided, including laptop, monitors, headset, keyboard, and mouse.
- Monthly connectivity reimbursement for eligible work-from-home employees.
- Salary range disclosed: $167,500 to $229,750 annually, based on experience and qualifications.