FREE ACCESS
5,000–10,000 jobs/day
See all jobs on JobTailor
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
About the role
Key responsibilities & impact- Provides clinical oversight and governance for the medical review program, including appeals, rescission, and grievance panel processes
- Conducts comprehensive clinical reviews for first and second-level appeals, including Department of Insurance (DOI) complaints
- Evaluates complex medical cases to ensure consistency with policy provisions, clinical guidelines, and regulatory requirements
- Provides expert clinical judgment in high-risk or sensitive determinations
- Provides independent clinical judgement in support of coverage determinations, free from claims or financial influence
- Supports alignment and consistency across appeal outcomes and internal review processes
- Leads clinical evaluation and decision-making for rescission cases and member grievances
- Ensures appropriate application of underwriting intent and policy interpretation in misrepresentation reviews
- Partners with legal on complex or escalated cases
- Partners with legal to ensure compliance with applicable state and federal requirements governing adverse benefit determinations, grievance processes, and clinical review standards
- Documents clinical rationale supporting determinations in a manner suitable for regulatory review, audits and litigation
- Identifies opportunities to improve upstream underwriting and risk selection practices
- Supports quality assurance and consistency of TPA decision-making
- Partners with product management and actuarial teams to inform product design and risk selection strategies
- Identifies trends and provides clinical insight on emerging risks, market trends, and competitive positioning
- Contributes to and helps advance initiatives to integrate AI and/or automation into medical review workflows
- Proactively identifies and raises opportunities to streamline processes and improve efficiency
- Partners with stakeholders to help maintain alignment on priorities, timelines, and expected outcomes
Requirements
What you’ll need- 4 year Bachelors Degree (Required)
- MD or DO (Required)
- 8 or more years of experience (Required)
- Active and unrestricted license to practice medicine (Required)
- Experience working with health insurance preferred
- MS Word, PowerPoint and Excel spreadsheet skills
- Effective communication skills, verbal and written
- Ability to handle shifting priorities
- Effective presentation skills including the ability to present complex medical risk information.
Benefits
Comp & perks- Allstate provides a comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse.
- Employees eligible to work from home also receive a monthly connectivity reimbursement to help offset internet costs.
- Reliable internet is required, with minimum speeds of 50 MB download and 5 MB upload.
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical oversightclinical reviewscoverage determinationsunderwriting intentpolicy interpretationrisk selectionmedical review workflowsemerging risksquality assuranceclinical judgment
Soft Skills
effective communicationpresentation skillsability to handle shifting prioritiesclinical insightstakeholder alignmentleadershipdecision-makingprocess improvementcollaborationproblem-solving
Certifications
MDDOactive medical license