Medical Director

Medical Director (Utilization Management) - Remote, US

Location: Remote (US)
Employment Type: Contract-to-Hire
Schedule: Full-time, 40 hours/week

We are seeking an experienced Medical Director to join a physician-led team responsible for utilization management and clinical review activities for a health insurance organization. This role focuses on evaluating medical necessity, appropriateness of care, appeals, and complex case reviews while ensuring compliance with applicable regulatory and accreditation standards.

The ideal candidate will have strong payer-side utilization management experience, excellent clinical judgment, and the ability to collaborate effectively with multidisciplinary teams to improve member outcomes and quality of care.

• Review escalated cases using established medical policies and clinical guidelines to determine medical necessity and appropriateness of services.
• Conduct peer-to-peer discussions with treating providers when required.
• Review appeals, grievances, and other medical determinations in accordance with regulatory and accreditation standards.
• Develop clear, concise, and defensible clinical rationales for coverage determinations.
• Participate in multidisciplinary case management and disease management discussions.
• Provide physician expertise for complex and high-risk cases.
• Support development and enhancement of clinical protocols, guidelines, and utilization review processes.
• Serve as a physician subject matter expert on strategic initiatives and special projects.
• Maintain compliance with NCQA, URAC, CMS, Department of Health (DOH), Department of Labor (DOL), and other applicable requirements.

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Active unrestricted medical license in Pennsylvania (PA), New York (NY), or West Virginia (WV).
• Board Certification in a specialty recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA).
• Minimum 5 years of direct patient care experience in a hospital, outpatient, or private practice setting.
• Experience in utilization management, care management, or managed care environments.
• Strong critical thinking, clinical decision-making, and case review skills.
• Excellent verbal and written communication skills.
• Ability to work collaboratively in a multidisciplinary team environment.
• Proficiency with clinical software and computer-based review systems.

• Experience working in medical management within a health insurance plan.
• Strong understanding of the managed care industry and payer-side utilization management.
• Experience using MCG and/or InterQual clinical criteria.
• MBA, MPH, or other related advanced degree.

• Fully remote opportunity within the United States.
• Must be a U.S. Citizen.
• Contract-to-hire position with long-term potential.
• Medical Director Assessment required as part of the selection process.
• Candidates should have the ability to manage a high volume of clinical reviews while maintaining quality and compliance standards.
• Experience with payer-side utilization management is highly preferred.

If you are a physician leader with a passion for clinical quality, utilization management, and improving healthcare outcomes, we encourage you to apply.