Remote Claims Resolution Specialist Jobs in Raleigh, NC

Overview

The Medical Director serves as the clinical leader and chairperson of the Credentialing Committee, providing oversight for provider credentialing, peer review activities, policy development, and quality assurance initiatives. This role ensures compliance with NCQA accreditation standards, applicable state and federal regulations, and organizational credentialing requirements. The Medical Director is responsible for maintaining the integrity of the credentialing process and supporting fair, evidence-based review and resolution of provider credentialing and claims-related matters.

This position will support as a consulting Medical Director role supporting a Credentialing Verification Organization (CVO), health plan, or utilization management operation

The Medical Director works collaboratively with organizational leadership, credentialing staff, peer reviewers, and regulatory stakeholders to ensure provider qualifications are evaluated consistently and in accordance with established standards. While this position allows remote work, the individual must reside within the state of North Carolina and travel to client sites as needed. 

This position is contingent upon contract award and funding approval. Candidates may be interviewed and selected in advance; however, employment and start dates are dependent upon successful contract award and operational need.Qualifications

Required Qualifications

• Doctor of Medicine (MD) degree from an accredited institution.
• Active and unrestricted North Carolina medical license.
• Current board certification in an applicable medical specialty.
• Must reside within the state of North Carolina. 
• Minimum five (5) years of clinical medical practice experience.
• Minimum three (3) years of experience supporting policy interpretation, utilization review, credentialing, claims resolution, or medical review functions within commercial and/or government-sponsored health insurance programs.
• Demonstrated knowledge of NCQA credentialing standards and accreditation requirements.
• Strong understanding of provider credentialing and peer review processes.
• Ability to pass any required background checks and drug screenings

Knowledge, Skills, and Abilities

• Strong clinical judgment and decision-making skills.
• Knowledge of provider credentialing regulations and best practices.
• Ability to interpret complex clinical information and regulatory requirements.
• Excellent written and verbal communication skills.
• Strong meeting facilitation and leadership abilities.
• Ability to work collaboratively with multidisciplinary teams.
• Demonstrated commitment to quality, compliance, and patient safety.

Preferred Qualifications

• Experience serving as a Medical Director for a health plan, managed care organization, CVO, or utilization management organization.
• Experience with Medicaid, Medicare, or state healthcare programs.
• Previous Credentialing Committee leadership experience.
• Familiarity with quality improvement and accreditation initiatives.

Responsibilities

Credentialing Committee Leadership

• Serve as Chair and voting member of the Credentialing Committee.
• Direct and oversee all Credentialing Committee operations.
• Appoint a qualified proxy to serve in the Medical Director's absence.
• Ensure Credentialing Committee activities comply with Department-approved bylaws and operating procedures.
• Lead committee meetings and facilitate informed credentialing decisions.

Governance and Compliance

• Follow and enforce Credentialing Committee Bylaws approved by the Department.
• Participate in ongoing review and revision of credentialing bylaws, policies, and procedures.
• Ensure compliance with NCQA accreditation requirements and applicable healthcare regulations.
• Support audits, accreditation reviews, and regulatory examinations.

Peer Review Oversight

• Coordinate and oversee peer review activities.
• Recruit and engage qualified peer reviewers.
• Ensure peer review determinations are objective, timely, and clinically appropriate.
• Provide clinical consultation regarding provider qualifications, performance concerns, and credentialing recommendations.

Clinical Policy and Claims Support

• Provide medical expertise for policy interpretation and implementation.
• Support resolution of clinical and claims-related issues affecting provider participation.
• Collaborate with health plan, quality, compliance, and operational teams to address complex clinical matters.
• Ensure consistency and appropriateness of clinical decision-making processes.

Strategic Collaboration

• Assist with the recruitment and onboarding of Credentialing Committee members.
• Participate in quality improvement initiatives related to provider credentialing.
• Provide recommendations to leadership regarding provider network quality and credentialing standards.
• Foster collaboration among credentialing, quality assurance, compliance, and clinical stakeholders.

This position is contingent upon contract award and funding approval. Candidates may be interviewed and selected in advance; however, employment and start dates are dependent upon successful contract award and operational need.

Senture, a TP company is home to a global family with people from various backgrounds and lifestyles. We will always embrace diversity and never discriminate against employees or applicants based on gender identity or expression, sexual orientation, race, religion, age, national origin, citizenship, disability, pregnancy status, veteran status, or other differences.

Employment Type: FULL_TIME