Medical Director (Utilization Management) – Remote (USA)

Job Summary

We are seeking an experienced Medical Director to join our Utilization Management team. In this fully remote role, you will perform medical necessity reviews, evaluate escalated utilization management cases, participate in peer-to-peer discussions with providers, and collaborate with multidisciplinary teams to ensure high-quality, evidence-based care. This opportunity is ideal for physicians with payer-side Utilization Management experience in the health insurance industry.

Responsibilities

• Review escalated Utilization Management (UM) cases using established medical policies and clinical guidelines.
• Determine medical necessity and appropriateness of requested services.
• Conduct peer-to-peer discussions with treating physicians when required.
• Review appeals, grievances, and prior authorization cases.
• Prepare clear, concise, and compliant determination letters.
• Ensure compliance with NCQA, URAC, CMS, DOH, and DOL regulations.
• Participate in multidisciplinary case management meetings and grand rounds.
• Provide clinical guidance on complex and high-risk cases.
• Assist in developing clinical protocols, policies, and review guidelines.
• Support strategic initiatives and projects as a physician subject matter expert.

Required Qualifications

• MD or DO degree.
• Active unrestricted medical license in PA, NY, or WV.
• Board Certified by an ABMS or AOA recognized specialty board.
• Minimum 5 Years Of Direct Patient Care Experience.
• Prior payer-side Utilization Management experience with a Health Insurance Plan.
• Experience reviewing medical necessity, prior authorizations, appeals, and grievances.
• Strong clinical judgment and critical thinking skills.
• Excellent written and verbal communication skills.
• Comfortable using electronic medical review systems.

Preferred Qualifications

• MBA or Master's in Public Health (MPH).
• Experience with MCG and/or InterQual criteria.
• Managed Care or Health Insurance Medical Management experience.
• Experience with Predictal and Beacon systems.

Additional Information

• 100% Remote (Work from anywhere in the U.S.).
• Contract-to-Hire opportunity.
• 40 hours per week.
• Medical Director Assessment required.
• Expected productivity: 55+ case reviews per day.

Candidates Should Indicate Whether They Specialize In Behavioral Health Physical Health (Non-Behavioral)

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