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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive clinical oversight and governance in medical review programs, with a strong focus on appeals, regulatory compliance, and risk assessment. Proven ability to lead cross-functional teams and apply clinical judgment in complex medical and insurance-related environments.
Highest-signal resume keywords
Doctor Of Medicine (MD) Or Doctor Of Osteopathic Medicine (DO)5+ Years Of Direct Clinical ExperienceActive, Unrestricted Medical LicenseCurrent Board Certification In ABMS SpecialtyProficiency With Microsoft Office Suite
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical OversightClinical ReviewRegulatory CompliancePolicy InterpretationRisk AssessmentData AnalysisAI And Automation AssessmentQuality AssuranceMedical ManagementUnderwriting Practices
Soft Skills
LeadershipCollaborationCommunicationInfluencingChange Management
Tools & Technologies
Microsoft WordMicrosoft PowerPointMicrosoft ExcelBusiness Applications
Certifications & Qualifications
Board Certification In ABMS SpecialtyACGME-Accredited Residency Completion
Industry Keywords
Health InsuranceClinical GuidelinesRegulatory RequirementsThird-Party AdministratorMedical Review Workflows
About the role
Key responsibilities & impact- Provide clinical oversight and governance for the medical review program, including appeals, rescission, and grievance panel processes
- Conduct comprehensive clinical reviews for first- and second-level appeals, including Department of Insurance complaints
- Evaluate complex medical cases for consistency with policy provisions, clinical guidelines, and regulatory requirements
- Provide expert clinical judgment for high-risk or sensitive determinations and coverage decisions
- Lead clinical evaluation and decision-making for rescission cases and member grievances
- Apply underwriting intent and policy interpretation in misrepresentation reviews
- Partner with legal and compliance teams on escalated cases, regulatory matters, litigation support, and state and federal requirements
- Document clinical rationale for regulatory review, audits, and litigation
- Identify opportunities to improve underwriting and risk selection practices
- Support quality assurance and consistency of Third-Party Administrator decision-making
- Partner with product management and actuarial teams on product design and risk selection strategies
- Identify emerging risks, market trends, and competitive positioning in health insurance
- Advance AI and automation initiatives in medical review workflows
- Streamline processes and improve operational efficiency
- Maintain alignment with stakeholders on priorities, timelines, and expected outcomes
- Serve as a clinical subject matter expert and trusted advisor to internal business partners
- Perform supervisory duties
- Support Allstate's Health Solutions business and clinical decision-making across health insurance products and medical management programs
Requirements
What you’ll need- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) from an accredited institution (Required)
- 5+ years of direct clinical experience post residency or fellowship (Required)
- Demonstrated experience applying clinical judgment in complex medical, regulatory, or insurance-related environments (Required)
- Proficiency with Microsoft Word, PowerPoint, Excel, and other business applications (Required)
- Active, unrestricted license to practice medicine in the United States; candidates must be in good standing and eligible to practice without restrictions, disciplinary actions, or limitations
- Current Board Certification in an American Board of Medical Specialties (ABMS) recognized specialty; board-eligible but not board-certified candidates will not be considered
- Board Certification must be maintained throughout employment
- Completed an ACGME-accredited residency program and any applicable fellowship training associated with the specialty
- Clinical training, licensure, and professional experience primarily obtained within the United States healthcare system
- Ability to craft and deliver clear, compelling, executive-ready messages and tailor content to diverse audiences
- Proven ability to lead large, multi-location teams through significant change, including transformations, systems implementations, and organizational integrations
- Ability to navigate complex organizational structures and matrixed environments
- Ability to influence and collaborate across cross-functional teams and leadership levels
- Track record of building, developing, and leading high-performing organizations
- Ability to apply analytical tools, data sources, and software applications
- Ability to assess responsible use of AI and automation, including related risks
- Background investigation required
- Allstate generally does not sponsor individuals for employment-based visas for this position
- Dedicated, private workspace when working from home
- Reliable internet with minimum speeds of 50 MB download and 5 MB upload
Benefits
Comp & perks- Comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse
- Monthly connectivity reimbursement to help offset internet costs
- Remote work arrangement
- Meaningful connection opportunities
- Opportunities to challenge the status quo and shape the future of protection
- Comprehensive employment benefits are referenced in the equal employment policy, but not itemized