Medical Director, Appeals (Remote)

Remote Medical Director, Appeals

Remote \| United States

An exceptional opportunity has arisen for an experienced physician leader to join a national healthcare organisation as a Remote Medical Director, Appeals.

This highly influential role will provide clinical leadership across medical management, utilisation review, quality improvement, and appeals functions, ensuring members receive appropriate, evidence-based care while supporting quality, compliance, and cost-effectiveness objectives.

Working closely with senior clinical leadership, provider networks, and multidisciplinary healthcare teams, the successful candidate will be responsible for reviewing complex medical necessity cases, supporting appeals processes, driving quality improvement initiatives, and contributing to strategic clinical decision-making across a large and diverse member population.

This role is ideally suited to a Board-Certified physician with strong utilisation management experience and a passion for improving healthcare outcomes through collaborative clinical leadership.

Key responsibilities include:

• Providing medical leadership for utilisation management, medical necessity reviews, appeals, and quality improvement activities

• Reviewing complex, high-profile, and medically challenging cases to ensure timely and evidence-based decision-making

• Collaborating with appeals teams, care management teams, network providers, pharmacy consultants, and clinical leadership to resolve complex clinical issues

• Supporting quality improvement programmes and identifying opportunities to improve care delivery and reduce unwarranted variation in clinical practice

• Assisting in the development of clinical policies, utilisation management strategies, and performance improvement initiatives

• Participating in provider engagement activities and supporting physician education programmes

• Reviewing claims involving complex, controversial, or emerging treatments and technologies

• Supporting accreditation, regulatory compliance, and quality management activities

• Representing the organisation with provider groups, professional organisations, and relevant healthcare committees where required

Candidates should demonstrate:

• MD or DO qualification with an active and unrestricted medical licence

• Active Board Certification in a recognised medical specialty

• Strong clinical experience combined with exposure to utilisation management, appeals, or medical management functions

• Excellent clinical judgement and medical necessity review expertise

• Strong communication and stakeholder management skills

• The ability to work effectively within a highly matrixed healthcare environment

Experience within managed care, health plans, utilisation review, quality improvement, or appeals environments would be highly advantageous. Board Certification in Internal Medicine or Family Medicine is particularly desirable.

This is a fantastic opportunity to join a large, mission-driven healthcare organisation where you will play a pivotal role in ensuring high-quality, evidence-based care for millions of members while contributing to broader healthcare strategy and clinical excellence initiatives.

Location: Remote

Salary: $236,500 – $449,300 \+ bonus and comprehensive benefits package

Please apply directly via LinkedIn