Medical Director - Medicare Appeals
Core
Lead Medicare Part C appeals for providers and members, managing the Second Look Review process and ensuring clinical consistency.
Role type
Senior Medical Director (Medicare Appeals)
Builds
Medicare appeals decisions and utilization management strategies
Domain
US Healthcare Insurance / Medicare
Required skills
Medicare policy expertise, clinical quality assessment, appeals process management, utilization management strategy, team supervision, after-hours coverage coordination
Preferred skills
Medical management experience, Medicare complaints/grievance/appeals handling, health plan experience
Technologies
None stated
Responsibilities
Direct daily work on Part C appeals, provide support to appeal nurses, manage Second Look Review process, provide after-hours coverage, monitor IRE and support utilization management, collaborate with Medicare Quality and Compliance, develop subject matter expertise, educate staff on policy, improve team efficiency
Seniority
Senior, hands-on IC with leadership responsibilities
