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Oregon Health & Science University

Portland, Oregon

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Michael Garron Hospital - Toronto East Health Network

Toronto, Ontario, Canada

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County of Alameda

Oakland, California

WellSpan Health

Stevens, Pennsylvania

University of Virginia

Charlottesville, Virginia

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AdventHealth

Davenport, Florida

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Denver Health

Denver, Colorado

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RWJBarnabas Health

Somerset, New Jersey

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BJC HealthCare

Saint Louis, Missouri

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Vanderbilt Health

Nashville, Tennessee

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BJC HealthCare

Saint Louis, Missouri

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AdventHealth

Davenport, Florida

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Rush University Medical Center

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Secaucus, New Jersey

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Optum

Altamonte Springs, Florida

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Medical Director Appeals Grievances
JOB SUMMARYThe Medical Director, Appeals and Grievances provides leadership for Community Health Choice medical management programs. This includes reviewing appeals of adverse determinations, tracking them and providing feedback to Medical Affairs on current overturn trends. In addition will provide clinical input and oversight for Care (Disease) Management, Quality Improvement, Credentialing, and Preventive Health programs. Will work with Provider Relations to maintain and improve relationships with the provider community especially with Value based arrangements. Will perform medical necessity reviews as assigned including reviews with peer-to- peer interactions as needed and other duties as assigned.


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