Position Title: Medical Director – Utilization Management (Experience Required)
Location: *Remote* (Anywhere in the U.S.)
Salary Range: $240,000 – $270,000 / year (commensurate with education, experience, and internal equity)
Position Type: Full-Time (Occasional weekend/holiday coverage required based on operational needs)
Role Summary
The Medical Director serves as a vital member of the Physical Health Medical Management Team, delivering clinical oversight, medical expertise, and operational leadership. This position ensures the highest standard of evidence-based medical reviews, supporting key organizational goals across clinical quality, utilization management (UM), and care coordination.While primarily remote, the selected candidate may be required to report on-site as needed.
Key Responsibilities & Duties
Clinical Oversight & Medical Review
- Provide expert clinical guidance and decision-making for physical health service requests, including authorizations and level-of-care determinations.
- Oversee the integrity and clinical quality of utilization management activities across inpatient and outpatient settings, including initial reviews, concurrent reviews, and appeals.
- Participate in internal case reviews to ensure compliance with regulatory, accreditation, and organizational standards.
Service & Level of Care Determinations
- Apply medical necessity criteria using established hierarchy standards for level of care, service type, amount, and duration.
- Consistently meet or exceed expected departmental case volume guidelines.
Process Adherence, Quality & Efficiency
- Conduct timely utilization reviews using internal UM platforms while adhering to approved organizational policies, desk procedures, and operational workflows.
- Ensure documentation accuracy, consistent decision-making, and full regulatory compliance across all case reviews.
Operational & Committee Leadership
- Actively participate in organizational committees, including Clinical Quality Review, Transition of Care Rounds, and the Overturn Committee.
- Provide clinical leadership to foster collaboration across medical, behavioral, and care management teams.
External Engagement & Legal Support
- Support mediation activities and Office of Administrative Hearing (OAH) processes by providing clinical expertise, testimony, and documentation support as needed.
- Continuous Improvement & Mentorship
- Stay current with regulatory updates, utilization management guidelines, and emerging physical health trends.
- Drive process improvement initiatives to optimize clinical quality, efficiency, and member outcomes.
- Mentor and train peers within the Medical Management team and assist with onboarding new Medical Directors.
- Provide clinical consultation, training, and education to internal staff and community partners.
Team Environment & Culture
- Partner with HR and leadership to recruit, support, and retain a high-performing medical management team.
- Promote a positive, inclusive, and equitable work environment built on trust, respect, and transparent standards.
Qualifications & Requirements
Education & Experience
- Medical Degree: Graduation from an accredited medical school (M.D. or D.O. required).
- Clinical Experience: Minimum of four (4) years of postgraduate clinical practice.
- Managed Care Experience: Minimum of two (2) years of managed care
- Utilization Review experience to include guidance and decision-making for healthcare service requests for initial reviews, concurrent reviews, and appeals.
Licensure & Certification
- Board Certification: Board Certified in a relevant field of medicine (American Board of Family Medicine or American Board of Internal Medicine).
- Medical License: Current, active, and unrestricted license to practice medicine in North Carolina (or eligible to obtain NC licensure upon hire).
- Knowledge, Skills & AbilitiesStrong knowledge of clinical diagnosis, treatment alternatives, pharmacology, and preventive health measures.
- In-depth understanding of managed care principles and utilization management workflows.
- Excellent interpersonal and communication skills to discuss complex cases, treatment concerns, and evidence-based recommendations with colleagues.
- Proficiency with Microsoft Office tools (Word, Excel, Teams, OneNote) and clinical review software platforms.
Benefits & Compensation
- We offer a competitive compensation package alongside comprehensive benefits, including:Health & Wellness: Comprehensive Medical, Dental, and Vision insurance, along with Life and Long-Term Disability coverage.
- Retirement: Generous retirement savings plan options.
- Work-Life Balance: Flexible work schedules with remote/hybrid arrangements and flexible dress code options.
- Paid Time Off: Generous PTO, including vacation, sick leave, paid holidays, and management leave.
