Lead MD Grievances & Appeals

Become a part of our caring community   The Lead Medical Director relies on fundamentals of CMS Medicare Guidance on following and reviewing appeals for Medicare Line of Business. The Lead Medical Director requires a solid understanding of how organization capabilities interrelate across department(s) and the fundamentals of using data analytics to drive results and trends. Candidates may live anywhere in the US, but must be willing to work East Coast hours. This role will work closely with our Appeal Strategy, Nurse Leaders and adjacent stakeholders and business partners. The Lead Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s) and could lead multiple highly specialized professional associates. The Lead Medical Director will be responsible for driving and managing the team's culture and engagement. Schedule is Monday-Friday with alternating weekend supervision AND an occasional weekend shift with days off during the week Use your skills to make an impact   Required Qualifications Current and ongoing board certification in an approved ABMS Medical Specialty A current and unrestricted license in at least one jurisdiction and willing to obtain additional licenses, as required, for various states in region of assignment 5+ years of direct clinical patient care experience post-residency or fellowship No current sanction from Federal or State Governmental organizations and the ability to satisfy onboarding requirements Excellent verbal and written communication skills with analytic and interpretative skills from prior experience focusing on quality, utilization, and/or case management Knowledge and experience with national guidelines such as NCD/LCD, MCG® or InterQual Preferred Qualifications Demonstrated experience in operations and performance management Demonstrated experience with appeals review cases with completion of training Experience in an inpatient and/or care of a Medicare type population (disabled or >65 years of age) Internal Medicine, Family Practice, Geriatrics, General Surgery, Neurology, Anesthesia background Two or more years of management experience leading teams in dynamic environments Commitment to a culture of innovation, diversity, equity, and inclusion Passionate about contributing to an organization's focus on consistency in outcomes, consumer experiences and a highly engaged team culture Reporting Structure In conjunction with the other G&A Lead Medical Directors, this position oversees the operations of the team, ensures timely completion of cases by the team to meet Medicare requirements, and oversees the work of Medical Directors who conduct appeals clinical case reviews for Medicare and Dual Eligible populations. The Lead Medical Director may also lead specific functional areas in addition to leading a team of Medical Directors. The role reports to the Director of Physician Leadership. Other Duties: Maintain medical director schedule (PTO, weekend coverage, etc.) Develop collaborative relationships with key partners within the Medicare Line of Business, including with internal team associates and leadership This position will require 50% case review. Manage regular meetings with various company participants Foster development of medical directors through non-case review activities Support team pursuit of CMS Star success in Timeliness and Fairness measures Other activities as assigned by the Director of Physician Leadership Work Style: Fully Remote; Very minimal travel might be required for training, meetings, and/or conferences Work Hours : Typical business hours are Monday-Friday, 8 hours/day, 5 days/week-- some flexibility might be possible, depending on business needs. Interview Format  As part of