Job Description Summary
The Utilization Management (UM) Medical Director provides clinical leadership for the UM program, ensuring members receive appropriate, high-quality care. You will oversee review guidelines, collaborate with internal teams and external partners, and drive compliance with regulatory and accreditation standards.
How will you make an impact & Requirements
**This is a remote position; however, candidates located in CA, NV, or AZ are preferred.**
CareMore Health is a physician-founded and physician-led organization that has been transforming care delivery since 1992. With 25 clinics, 65,000+ members and partnerships with 30+ health plans, we’ve built a reputation for delivering exceptional, integrated healthcare experiences to Medicare, Medicaid, and group or private plan members.
Our mission is simple: to improve health outcomes by delivering a transformative and integrated healthcare experience impacting physical, social and emotional well-being. Cultivating life-long relationships with patients, grounded in compassion and unwavering dedication to excellence in care, we’ve built care teams around our patients’ needs — including doctors, nurse practitioners, case managers, community health workers, social workers, pharmacists and specialists, all working together to produce the best outcomes possible. This people-first, value-based model ensures physicians can practice medicine the way it was meant to be practiced — with time to connect, collaborate, and truly care for patients.
Key Responsibilities
- Lead the development, implementation, and periodic review of UM policies and clinical criteria
- Provide physician oversight for concurrent and retrospective review activities
- Approve and interpret clinical guidelines, pathways, and criteria for admission, continued stay, and discharge
- Serve as the primary clinical liaison with payers, providers, and regulatory bodies
- Mentor and educate UM nurses, physician reviewers, and other staff on best practices
- Analyze utilization data and quality metrics to identify trends and areas for improvement
- Participate in appeals and peer-to-peer discussions to resolve clinical disputes
- Maintain compliance with NCQA, URAC, CMS, state regulations, and organizational standards
- Participation in the physician call rotation, requiring coverage for one full weekend (Saturday and Sunday) approximately every four to five weeks. As compensation, one half-day of flex time (AM or PM) is provided during the following work week
Qualifications
- Medical degree (MD or DO) from an accredited institution
- Active, unrestricted medical license in [State/Region]
- Board certification in an acute-care specialty (e.g., Internal Medicine, Family Medicine, Pediatrics)
- Minimum of 5 years clinical practice experience, with 2+ years in utilization management or managed care
Location
- Preference for candidates in CA, NV, or AZ
- Requires availability to work standard Pacific Time Zone business hours, regardless of physical location
**The posted compensation range represents the national market average. Compensation for roles located in premium or high-cost geographic markets may fall above this range. This position is bonus eligible based on individual and company performance.**
