Medical Director - Utilization Management - 253754

Medical Director – Utilization ManagementRemote | Full-Time (40 hrs/week)We are partnering with a national health plan organization to identify an experienced Utilization Management Medical Director to support a high-volume, payer-side clinical review operation. This role is part of a large-scale UM transformation focused on improving efficiency, consistency, and quality of medical necessity determinations.Position OverviewThe Medical Director will conduct utilization management reviews, support escalated clinical decisions, and ensure adherence to regulatory and medical policy standards. This is a production-based, remote role requiring prior health plan UM experience and the ability to work independently in a fast-paced environment.Key ResponsibilitiesPerform utilization management reviews for medical necessity and appropriateness of careReview escalated cases using established medical policy criteriaParticipate in peer-to-peer discussions with treating providersSupport prior authorization determinations, appeals, and grievance reviewsEnsure compliance with NCQA, CMS, URAC, and internal health plan guidelinesCollaborate with clinical and operational leadership to optimize workflow efficiencyProvide clinical expertise for complex and high-acuity casesMaintain productivity expectations in a high-volume review environmentRequired QualificationsMD or DO from an accredited institutionBoard Certified (Internal Medicine or Family Practice preferred)Active, unrestricted U.S. medical licenseMust hold at least one active license in: Pennsylvania (PA), West Virginia (WV), or New York (NY)Multiple years of payer-side / health plan Utilization Management experience as a Medical DirectorDirect experience performing utilization review within a health plan settingStrong understanding of managed care operations and medical necessity criteriaAbility to work independently in a remote, production-based environmentPreferred ExperienceMedicare Advantage and/or Commercial health plan experiencePrior authorization review experienceAppeals and grievance review experiencePeer-to-peer review experienceMulti-state licensureGeneral inpatient and outpatient utilization review experienceWork Schedule & TrainingStandard schedule: ~8:30 AM – 5:00 PM40 hours per weekIdeal Candidate ProfileStrong clinical judgment and decision-making abilityComfortable conducting peer-to-peer discussions with providersHighly independent in a remote environmentCollaborative with clinical and operational teamsAdaptable and efficient in high-volume UM workflowsPerks!High-impact role within a national health plan organizationFully remote, stable 40-hour work weekImmediate contribution with minimal ramp-up for experienced UM physiciansExposure to broad utilization management across multiple lines of businessContract-to-hire pathway for long-term opportunity