Medical Director, Utilization Management – Part-Time

Mascmedical; San Diego (CA); On-site; USD 192,000 - 261,000; Part time

Job summary

MASC Medical is recruiting a part-time Medical Director of Utilization Management for a San Diego PACE program, serving frail, dual-eligible older adults. This 20-hour-a-week leadership role has no patient panel or on-call duties and focuses on medical necessity determinations across care settings.

You will lead peer-to-peer discussions, oversee appeals, and guide CMS/Medi-Cal/PACE-compliant utilization decisions, while steering policy and program integrity.

Qualifications

• Active, unrestricted California MD or DO license.
• Active DEA registration.
• Current BLS.
• Board certified/eligible in a primary care specialty.
• 5+ years of clinical practice in Internal Medicine, Geriatrics, or Family Medicine.
• 3+ years in utilization/resource management or medical leadership.
• Working knowledge of Medicare and Medi-Cal/CMS regulations and criteria.

Responsibilities

• Make and direct medical necessity determinations across outpatient, inpatient, and post-acute care settings.
• Apply InterQual and CMS criteria; train the team on usage.
• Lead peer-to-peer discussions with site medical directors, PCPs, and external providers.
• Serve as physician reviewer on escalated and complex utilization cases.
• Lead and protect the integrity of the appeals and grievance process under CMS, Medi-Cal, and PACE.
• Support authorization review, concurrent review, and denial management with UM staff.
• Monitor for over- and under-utilization and identify patterns driving admissions and LOS.
• Oversee HCC/ICD-10 coding and RAF accuracy.
• Develop medical policy and drive evidence-based guideline adoption.
• Partner with the CMO and interdisciplinary teams.
• Chair or participate in credentialing and P&T committees.
• Document to PACE, NCQA, and CMS standards and support audits.

Skills

Medical leadership

Utilization management

Internal Medicine

Geriatrics

Family Medicine

CMS / Medi-Cal knowledge

Education

MD or DO

Board certification in primary care

Job description

MASC Medical is recruiting a part-time Medical Director of Utilization Management for a San Diego PACE program, serving frail, dual-eligible older adults. This 20-hour-a-week leadership role has no patient panel or on-call duties and focuses on medical necessity determinations across care settings.

You will lead peer-to-peer discussions, oversee appeals, and guide CMS/Medi-Cal/PACE-compliant utilization decisions, while steering policy and program integrity.