Medical Director Appeals, Grievances & Disputes

Job description

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical). KHS reasonably expects to pay starting compensation for the position of Medical Director, Appeals, Grievances & Disputes in the range of $257,050 – $340,591.50 annually. Our Mission.. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system. About the role The Medical Director of Appeals and Grievances (A&G) and Provider/Consumer Complaints and Dispute is responsible for leadership, operational execution, clinical and regulatory oversight, and enterprise governance of Kern Health System’s grievance, appeal, and State Fair Hearing functions across all product lines. This position ensures all cases are processed accurately and consistently with exceptional quality, and within required timeframes in alignment with federal and state regulations, contractual obligations, accreditation standards, and internal policies. The Medical Director directs a comprehensive operating model that includes centralized intake and triage, general and clinical A&G operations, regulatory auditing and reporting, quality assurance, internal controls, and enterprise-level grievance governance. The Medical Director oversees staff and ensures the organization maintains strong regulatory compliance, service quality, and documentation standards. The Medical Director collaborates extensively with cross-functional key stakeholders to address systemic issues, strengthen preventive controls, improve service delivery, and support enterprise audit readiness. The Medical Director embodies a commitment to operational excellence, accountability, equitable member experience, and disciplined governance. Core Responsibilities Core responsibilities encompass supervision of intake, triage processes, case documentation, and clinical decision-making, alongside engagement in State Fair Hearings and the preparation of regulatory submissions. Acting as the primary liaison to external organizations, the Medical Director provides internal guidance, responds to provider and member queries, and collaborates with interdisciplinary teams to develop strategies that resolve systemic challenges. Drawing upon clinical acumen, this role entails review of A&G cases and provider dispute resolutions by managing issues ranging from moderate to significant complexity. The Medical Director provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with standardized and approve policies, procedures, and performance standards. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action. Essential Functions • Reviews medical records or case files and writes a clear and impartial reconsideration or dispute resolution decision supporting the determination and documents the review. • Conducts medical necessity evaluations with complete clinical documentation and follows evidence-based guidelines to ensure quality member care. • Collaborates with grievance and appeals to staff to support clinical decisions and quickly identify, escalate, and resolve quality-of-care issues. • Ensures consistency in documentation of clinical rationale, decision accuracy, and regulatory adherence across all clinical case types. • Examines emerging patterns and works with network management to address challenges related to access, availability, operations, and quality. • Actively participates in team meetings focused on communication, feedback, problem solving, process improvement, staff training and evaluation, and the sharing of program results • Offers medical interpretation and assesses the suitability of other healthcare professionals' services in accordance with review guidelines and performance standards. • Adheres to company policies and procedures, in addition to federal and state regulations governing grievances and appeals. • Promotes an environment of ongoing enhancement and innovation within the grievances and appeals department. • Acts as a bridge between members and healthcare providers to ensure grievances and appeals are resolved promptly and appropriately. • Stays informed about industry trends and best practices related to member satisfaction and grievances and appeals processes. • Participates in the technological advancement of the Appeals and Grievance database and dashboards. • Engages in continuous strategies to strengthen the infrastructure of the Appeals and Grievance department. • Provides support to the Quality Improvement department through participation in targeted quality studies and evaluations. • Establishes key performance indicators to track progress and enhance the Quality Improvement Department. • Serves as chair of the Appeals and Grievance Committee and promotes best practices and regulatory compliance. • Attends all regulatory audits as the primary representative of the appeals department. • Guides the Appeals and Grievance Department through complex regulatory audits, consistently securing compliant results and implementing lasting remediation strategies. Leadership – People and Operations • Leads enterprise-wide integration of A&G insights into systemic improvements and supports risk mitigation across operational domains. • Partners with internal departments to resolve root-cause issues and reduce grievance drivers. • Collaborates with internal departments to support regulatory filings, investigations, enterprise risk assessments, and Corrective Action Plan management. • Engage with external stakeholders to resolve escalated member issues and improve service continuity. • Provides leadership support and A&G expertise in enterprise forums, oversight committees, and quality and service governance structures. • Ensures transparent, accurate, and actionable reporting that supports operational decision-making and continuous improvement. • Oversee reporting of case volumes, trends, timeliness, quality-of-care findings, regulatory metrics, and systemic issues. • Ensures high-quality analytics that inform operational refinements, service improvements, and strategic initiatives. • Presents findings to key stakeholders, identifying opportunities for enterprise improvement. • Promotes a culture of operational excellence, service commitment, accountability, integrity, and continuous learning. • Develop and implement communication strategies. • Collaborates with cross-functional teams to achieve common goals. • Represents the company or organization in external interactions. • Identifies and actualizes enhancements to support company vision. • Develops and maintains relationships with key stakeholders. • Perform other duties as assigned. Leadership – Business and Strategy • Exceptional interpersonal and leadership capabilities, with the ability to inspire, develop, and empower teams while driving accountability, consistency, and high performance across all levels. • Expert knowledge of grievance, clinical decision-making, and managed care regulatory standards, with the ability to translate complex requirements into effective operational processes. • Advanced strategic and analytical skills to interpret trends, assess operational and regulatory risk, and design sustainable, data-driven solutions. • Deep and comprehensive understanding of regulatory requirements for all lines of business. • Effective leadership in complex, high-volume, and highly regulated environments with competing priorities, rapid demand shifts, and significant compliance requirements. • Exceptional influence and stakeholder engagement skills to translate complex concepts into clear, actionable guidance for diverse audiences. • Strong leadership presence and leadership acumen, with demonstrated success managing, mentoring, and developing multi-level teams in operational and regulatory disciplines. • Design, implement, and sustain standardized processes, governance frameworks, and internal control structures that enhance accuracy, compliance, and operational reliability. • Strong planning, prioritization, and organizational skills with attention to detail and a proven ability to manage multiple concurrent priorities with urgency, accuracy, and sound judgment. • Lead comprehensive regulatory audit readiness and response efforts, including universe submissions, documentation validation, corrective action development, and sustainability planning. • Lead operational transformation initiatives while maintaining a strong culture of regulatory compliance, accountability, and service excellence. • Lead technology-enabled operational improvements, including system implementation, enhancement prioritization, and maintenance oversight to drive efficiency and reliability. • Develop long-term strategies that align with the overall goals of the organization. Employment Standards: • MD or DO with an active, unrestricted license in California • Board Certified in an ABMS or AOBMS specialty preferred • 5 years minimum clinical practice experience • 2 years minimum experience of grievance and appeals management at a Managed Care health plan or similar business model • 2 years minimum Quality of Care Management experience • Experience in Medicaid and Medicare managed care lines of business, with deep understanding of their operational, regulatory, and service requirements. • Experience navigating regulatory and accreditation requirements, with a strong track record of applying complex regulatory standards to grievance, appeal, and quality-of-care operations. • Experience improving operational accuracy, strengthening documentation quality, and ensuring consistent alignment with federal and state regulatory expectations. • Experience leading organizations through high-stakes regulatory audits, with a consistent record of achieving compliant outcomes and driving sustainable remediation. Preferred Competencies and Skills • Extensive experience working within delegated, plan-partner, or subcontracted network environments, with demonstrated ability to oversee performance, ensure compliance, and manage complex accountability structures. • Experience leading vendor management activities, including performance oversight, Service Level Agreement (SLA) adherence, quality monitoring, and alignment with regulatory and contractual requirements. • Experience developing analytic dashboards and visualization tools (e.g., Power BI, Tableau) to support trend analysis, performance monitoring, and decision-making. We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.