Medical Director Appeals, Grievances & Disputes

KHS•Bakersfield, CA

15h

About The Position

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.

Requirements

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

Nice To Haves

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

Responsibilities

Supervise intake, triage processes, case documentation, and clinical decision-making.
Engage in State Fair Hearings and prepare regulatory submissions.
Act as the primary liaison to external organizations.
Provide internal guidance and respond to provider and member queries.
Collaborate with interdisciplinary teams to develop strategies that resolve systemic challenges.
Review A&G cases and provider dispute resolutions, managing issues from moderate to significant complexity.
Provide medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with standardized policies, procedures, and performance standards.
Exercise independent judgment and decision-making on complex issues and work under minimal supervision.
Review medical records or case files and write clear, impartial reconsideration or dispute resolution decisions.
Conduct medical necessity evaluations with complete clinical documentation following evidence-based guidelines.
Collaborate with grievance and appeals staff to support clinical decisions and resolve quality-of-care issues.
Ensure consistency in documentation of clinical rationale, decision accuracy, and regulatory adherence across all clinical case types.
Examine emerging patterns and work with network management to address challenges related to access, availability, operations, and quality.
Actively participate in team meetings for communication, feedback, problem-solving, process improvement, staff training, and evaluation.
Adhere to company policies and procedures, and federal and state regulations governing grievances and appeals.
Promote an environment of ongoing enhancement and innovation within the grievances and appeals department.
Act as a bridge between members and healthcare providers to ensure grievances and appeals are resolved promptly and appropriately.
Stay informed about industry trends and best practices related to member satisfaction and grievances and appeals processes.
Participate in the technological advancement of the Appeals and Grievance database and dashboards.
Engage in continuous strategies to strengthen the infrastructure of the Appeals and Grievance department.
Provide support to the Quality Improvement department through participation in targeted quality studies and evaluations.
Establish key performance indicators to track progress and enhance the Quality Improvement Department.
Serve as chair of the Appeals and Grievance Committee and promote best practices and regulatory compliance.
Attend all regulatory audits as the primary representative of the appeals department.
Guide the Appeals and Grievance Department through complex regulatory audits, securing compliant results and implementing remediation strategies.
Lead enterprise-wide integration of A&G insights into systemic improvements and support risk mitigation.
Partner with internal departments to resolve root-cause issues and reduce grievance drivers.
Collaborate 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.
Provide leadership support and A&G expertise in enterprise forums, oversight committees, and quality and service governance structures.
Ensure 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.
Ensure high-quality analytics that inform operational refinements, service improvements, and strategic initiatives.
Present findings to key stakeholders, identifying opportunities for enterprise improvement.
Promote a culture of operational excellence, service commitment, accountability, integrity, and continuous learning.
Develop and implement communication strategies.
Represent the company or organization in external interactions.
Identify and actualize enhancements to support company vision.
Develop and maintain relationships with key stakeholders.
Design, implement, and sustain standardized processes, governance frameworks, and internal control structures.
Lead comprehensive regulatory audit readiness and response efforts.
Lead operational transformation initiatives while maintaining a strong culture of regulatory compliance.
Lead technology-enabled operational improvements, including system implementation, enhancement prioritization, and maintenance oversight.
Develop long-term strategies that align with the overall goals of the organization.