Role Description
The Regional Medical Director, Pre-Service Utilization Management (UM) is a full-time remote role responsible for overseeing clinical decision-making and medical necessity review processes for pre-service requests across an assigned region. This role provides clinical leadership to UM teams, reviews complex cases, and ensures that pre-service determinations align with evidence-based guidelines, regulatory requirements, and organizational policies. Day-to-day responsibilities include collaborating with physicians and other clinicians, rendering peer-to-peer determinations, supporting appeals, and guiding the application of clinical criteria.
The Regional Medical Director partners with operations, quality, and compliance teams to improve workflows, reduce unnecessary utilization, and enhance patient outcomes. This position also involves participating in performance improvement initiatives, educating UM staff on clinical protocols, and serving as a clinical resource for internal and external stakeholders.QualificationsStrong clinical foundation in Medicine with board certification or board eligibility and active, unrestricted medical license.
- Specialized expertise or significant experience in one or more of the following: Cardiology, Neurology, or Oncology.
- Demonstrated experience working with physicians and interdisciplinary clinical teams in a collaborative, advisory, or leadership capacity.
- Background in utilization management, care management, or health plan medical management, including familiarity with evidence-based guidelines and regulatory standards.
- Excellent clinical judgment, analytical skills, and ability to assess complex cases and apply standardized criteria consistently.
- Strong written and verbal communication skills, including comfort with peer-to-peer discussions and clear documentation of determinations.
- Proven ability to work effectively in a remote environment, manage time efficiently, and handle multiple priorities across a regional scope.
- Prior leadership experience in a health plan, hospital, or large clinical practice is highly beneficial.
- Commitment to equitable, patient-centered care and continuous quality improvement.
