Physician Reviewer, Appeals Anywhere in the U.S.

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

Job Responsibilities:

• Review clinical documentation and case records for appeals and grievances involving denied services for Medicare populations.
• Apply evidence-based guidelines, clinical judgment, and medical policy to assess medical necessity and appropriateness of care.
• Render determinations in accordance with applicable regulations (e.g., CMS, NCQA, URAC), contractual obligations, and clinical best practices.
• Provide clear, concise, and well-supported written rationales for all decisions and benefit interpretations.
• Participate in peer-to-peer discussions with attending providers, when appropriate.
• Ensure timely review and resolution of cases in accordance with organizational and regulatory timelines.
• Collaborate with medical directors, case managers, and legal/compliance teams as needed.
• Maintain strict confidentiality of all patient and proprietary information.
• Stay current with clinical guidelines, medical advancements, and regulatory changes.

Job Requirements:

Experience:

Required:

• 3-5 years of clinical practice experience.
• Strong knowledge of medical necessity criteria (e.g., MCG, InterQual), CMS guidelines, and health plan operations.

Preferred: Experience in utilization management, appeals, peer review, or managed care

Education and Licensure

Required:

• MD or DO with an active, unrestricted medical license in CA, AZ, NV, TX and/or NC.
• Board certification in a clinical specialty Internal Medicine or Family Medicine preferred

Preferred: Multistate licensure or compact state license

Specialized Skills

Required:

• Excellent written and verbal communication skills.
• Basic computer skills, typing, word processing, presentation and internet researching skills.
• Ability to work independently and manage multiple appeals reviews under tight deadlines.

Preferred:

• Familiarity with healthcare regulations especially Medicare.
• Proficiency with electronic health record (EHR) systems and clinical review software.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].