Job DescriptionThis role is part of Allstate's Health Solutions business and supports clinical decision-making across health insurance products and medical management programs.
The Medical Director is a highly experienced physician responsible for providing clinical expertise, oversight, and strategic guidance across medical management functions within Allstate's Health Solutions organization. This role supports complex clinical decision-making, including appeals, rescissions, grievance reviews, and Department of Insurance (DOI) complaints, while partnering closely with legal, product, underwriting, actuarial, and operational teams.
In addition, this role contributes to advancing innovation within Medical Management, including supporting the adoption of artificial intelligence (AI) and process improvements to enhance the efficiency, accuracy, and scalability of misrepresentation and clinical review processes. The position proactively partners with cross-functional teams to drive initiatives forward and maintain alignment on priorities, timelines, and expected outcomes.
As a Director, you won't just deliver results - you drive our culture and shared purpose. You can work remotely and will commute to a nearby office and/or travel for meaningful connection opportunities.
KEY RESPONSIBILITIES- Provides clinical oversight and governance for the medical review program, including appeals, rescission, and grievance panel processes.
- Conducts comprehensive clinical reviews for first- and second-level appeals, including Department of Insurance (DOI) complaints.
- Evaluates complex medical cases to ensure consistency with policy provisions, clinical guidelines, and regulatory requirements.
- Provides expert clinical judgment in high-risk or sensitive determinations.
- Provides independent clinical judgment in support of coverage determinations, free from claims or financial influence.
- Supports alignment and consistency across appeal outcomes and internal review processes.
- Leads clinical evaluation and decision-making for rescission cases and member grievances.
- Ensures appropriate application of underwriting intent and policy interpretation in misrepresentation reviews.
- Partners with legal and compliance teams on escalated cases, regulatory matters, litigation support, and interpretation of state and federal requirements impacting clinical review activities.
- Documents clinical rationale supporting determinations in a manner suitable for regulatory review, audits, and litigation.
- Identifies opportunities to improve upstream underwriting and risk selection practices.
- Supports quality assurance and consistency of Third-Party Administrator (TPA) decision-making.
- Partners with product management and actuarial teams to inform product design and risk selection strategies.
- Identifies trends and provides clinical insight on emerging risks, market trends, and competitive positioning within the health insurance industry.
- Contributes to and helps advance initiatives that integrate AI and automation into medical review workflows.
- Proactively identifies opportunities to streamline processes and improve operational efficiency.
- Partners with stakeholders to maintain alignment on priorities, timelines, and expected outcomes.
- Serves as a clinical subject matter expert and trusted advisor to internal business partners on medical management and policy-related matters.
SUPERVISORY RESPONSIBILITIES- This job has supervisory duties.
EDUCATION AND EXPERIENCE- 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).
- Experience within health insurance, managed care, health plan, payer, or medical management organization, including the ability to perform peer-level review of medical necessity, pre-existing condition, and coverage determinations (Preferred).
- Experience supporting appeals, grievances, utilization management, rescissions, or other health plan clinical review functions (Preferred).
- Experience partnering with legal, compliance, underwriting, product, actuarial, and operational teams (Preferred).
- Experience leading clinical process improvements, quality initiatives, or technology-enabled transformation efforts (Preferred).
- Significant experience working within a health insurance, managed care, payer, or health plan environment, including medical management, appeals, grievances, utilization management, or related clinical review functions (Preferred).
- Serves as a trusted clinical advisor to executive leadership, providing medical perspectives that inform strategic business decisions, risk management activities, and product development initiatives (Preferred).
- Strong understanding of health insurance products, policy interpretation, risk selection, and medical management practices (Preferred).
CERTIFICATIONS, LICENSES, AND REGISTRATIONS- Active, unrestricted license to practice medicine in the United States is required. Candidates must be in good standing and eligible to practice medicine without restrictions, disciplinary actions, or limitations.
- Current Board Certification in an American Board of Medical Specialties (ABMS) recognized specialty is required. Candidates who are board eligible but not board certified will not be considered.
- Board Certification must be maintained throughout employment.
- Candidates must have completed an ACGME-accredited residency program and any applicable fellowship training associated with their specialty.
- Clinical training, licensure, and professional experience must have been obtained primarily within the United States healthcare system.
- Preference will be given to physicians with experience applying their clinical expertise within health insurance, managed care, utilization management, appeals and grievances, or medical director functions.
FUNCTIONAL SKILLS AND CAPABILITIES- Executive Communication: Exceptional communication skills with the ability to craft and deliver clear, compelling, and executive ready messages. Adept at tailoring content to diverse audiences, simplifying complex concepts, and presenting confidently to senior leadership, stakeholders, and cross-functional partners
- Change Leadership: Proven ability to lead large, multi-location teams through significant change, including business transformations, systems implementations, and organizational integrations.
- Organizational Agility & Navigation: Effectively navigates complex organizational structures, building strong cross-functional relationships and influencing across multiple layers. Demonstrates the ability to operate with clarity and confidence in matrixed environments, ensuring alignment and progress amid complexity.
- Influence: Ability to influence and collaborate effectively across cross-functional teams and leadership levels.
- People Leadership & Talent Development: Track record of building, developing, and leading high performing organizations; establishes clear decision rights, accountability, and operating cadence while developing future leaders and succession pipelines.
- Technical & Analytical Skills: Ability to quickly master and apply a broad range of analytical tools, data sources, and software applications
- Technology, AI & modernization judgment: Assessing where AI and automation meaningfully improve efficiency and outcomes, and where they introduce risk, while guiding responsible, governed adoption.
SkillsClinical Decision Support (CDS), Clinical Review, Evaluating New Technologies, Executive Communications, Executive Influence, Insurance, Medical Management, Microsoft Office, People Leadership, Stakeholder Management
CompensationCompensation offered for this role is 167,500.00 - 229,750.00 annually and is based on experience and qualifications.
Allstate provides a comprehensive technology setup, including a laptop, monitors, headset, keyboard, and mouse. Employees eligible to work from home also receive a monthly connectivity reimbursement to help offset internet costs.
When working from home, you must have a dedicated, private workspace free from distractions, along with appropriate desk and seating. Reliable internet is required, with minimum speeds of 50 MB download and 5 MB upload.
To help create a more personal and engaging experience, we ask that you join with your camera on if your interview is virtual. Please also have a Valid Photo Identification available at the start of your interview. If you require any accommodations or have questions ahead of your interview please reach out to your recruiter.
Note: Internal candidates are only asked to join on video; a Valid Photo Identification is not needed for the interview.
