Medical Director, Appeals

Description:
The Medical Director, Appeals is responsible for physician-level review of medical appeals involving medical necessity, coverage determinations, and adverse clinical decisions within a Medicare Advantage environment.

This role evaluates clinical documentation, prior authorization decisions, applicable Medicare and CMS requirements, coverage criteria, and health plan policies to determine whether adverse determinations should be upheld, modified, or overturned.

The Medical Director, Appeals works closely with Utilization Management, Appeals and Grievances, nursing teams, clinical leadership, and other operational stakeholders to ensure appeal determinations are clinically appropriate, compliant, timely, and thoroughly documented.

What You Will Do:

• Conduct physician-level review of pre-service and post-service medical appeals involving medical necessity and coverage determinations.
• Review clinical records, prior authorization decisions, supporting documentation, and provider-submitted information.
• Apply CMS Medicare Advantage requirements, Medicare coverage guidelines, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and established clinical criteria.
• Make independent clinical determinations to uphold, modify, or overturn adverse coverage decisions within delegated authority.
• Review appeal cases independently when required, including cases where the reviewing physician was not involved in the original adverse determination.
• Provide clear, concise, and defensible clinical rationale supporting appeal determinations.
• Complete standard and expedited appeal reviews within applicable regulatory and operational turnaround times.
• Collaborate with Utilization Management nurses, Appeals and Grievances teams, other Medical Directors, and clinical leadership.
• Participate in physician-to-physician discussions and clinical case reviews when appropriate.
• Identify trends related to denials, appeals, clinical documentation, medical necessity criteria, or provider practices.
• Support compliance with CMS, Medicare Advantage, HIPAA, internal policies, and applicable accreditation requirements.
• Assist with the development, refinement, and implementation of clinical review policies, appeal processes, and utilization management workflows.
• Support regulatory audits, compliance reviews, and quality improvement initiatives related to medical management and appeals.
• Serve as a clinical subject matter expert for complex medical necessity and coverage-related cases.

You Will Be Successful If:

• You are comfortable making independent and defensible clinical decisions based on medical records, regulatory requirements, and evidence-based criteria.
• You have a strong understanding of Medicare Advantage utilization management and appeals processes.
• You can interpret and apply CMS guidance, NCDs, LCDs, health plan policies, and medical necessity criteria.
• You are able to manage a high-volume caseload while consistently meeting regulatory turnaround times.
• You communicate complex clinical decisions clearly and professionally in written and verbal formats.
• You work effectively with clinical, operational, compliance, and administrative teams.
• You demonstrate sound clinical judgment and maintain consistency when evaluating complex or disputed cases.
• You are detail-oriented and maintain accurate documentation that can withstand regulatory or audit review.
• You can identify recurring clinical or operational trends and recommend opportunities for process improvement.
• You are comfortable working in a highly regulated healthcare environment.

What You Will Bring:

• MD or DO degree from an accredited medical school.
• Current and unrestricted U.S. medical license.
• Board certification in an applicable medical specialty.
• Five or more years of clinical practice experience preferred.
• Previous experience in utilization management, medical necessity review, physician advisory services, appeals, or health plan medical management strongly preferred.
• Medicare Advantage experience strongly preferred.
• Experience reviewing medical necessity determinations, prior authorization requests, denials, and appeals.
• Working knowledge of CMS Medicare Advantage regulations and coverage requirements.
• Familiarity with NCDs, LCDs, evidence-based clinical guidelines, and medical necessity criteria.

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That’s Impresiv!