Position Summary:

Responsible for the administration of medical management services for the areas of Claims, Medical Review and Appeals for the Commercial Business. Serves as a subject matter expert lending direction and oversight to the execution of claims editing/coding initiatives, medical review operations and appeals management. Ensures that programs supports overall QI program and meets regulatory compliance/accreditation and Company standards. Assists in developing the strategic direction and oversight requirements to deploy for the clinical grievances/appeals unit to ensure consistency of practice and regulatory compliance. Promotes adherence to medical policy and appropriately direct payment for services in line with member benefits that are medically appropriate and necessary. Leads initiatives aimed at optimizing the cost of care while improving quality. Assists in the development and implementation of new programs, processes, and practices in response to medical, operational, service and regulatory challenges. Essential duties may include, but are not limited to: Interprets existing policies and develops new policies based on changes in the healthcare or medical arena. Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality, cost and outcomes. Supports the Medical Management staff ensuring timely and consistent responses to members and providers. Identifies and develops opportunities for innovation to increase effectiveness and quality. Serves as a resource and consultant to other areas of the company and may chair or serve on company committees.

Active, unrestricted medical license with current Cardiology Board Certification required. 7+ years clinical experience with exceptional oral and interpersonal communication skills required. Advanced analytical and problem-solving skills required. Excellent computer skills, tactical planning, and organizational skills also required. Proven leadership and project management skills essential.

For additional information and/or confidential consideration, please contact Tricia French at or (757)362-0202.