Medical Director, Utilization Management & Payer Strategy

Council Capital; United States; Remote; USD 180,000 - 300,000; Full time

Job summary

Council Capital is seeking a physician leader to guide utilization management for our portfolio companies. You will serve as the primary physician resource for UM decision-making, medical necessity determinations, and complex case reviews.

This role requires collaboration with clinicians, payers, and internal teams to drive high-quality outcomes across multi-site healthcare services. The successful candidate will bring MD/DO licensure, board certification, and proven experience in utilization

Qualifications

• MD or DO with an active, unrestricted medical license.
• Board certification in a relevant specialty.
• Experience in Utilization Management, Physician Advisory, Medical Review, or similar role.
• Strong understanding of medical necessity, payer criteria, and utilization standards.
• Ability to communicate effectively with clinicians and non-clinical leaders.

Responsibilities

• Serve as the primary physician resource for UM decision-making, escalations, and complex case reviews.
• Provide clinical oversight and guidance for medical necessity determinations.
• Support concurrent and retrospective review processes as needed.
• Conduct physician-to-physician reviews with payers to support authorization approvals and overturn denials.
• Partner with UM and Revenue Cycle teams to improve payer communication strategies.
• Identify payer-specific trends and opportunities to improve outcomes.
• Educate providers on documentation best practices tied to medical necessity and payer criteria.
• Identify recurring documentation gaps and implement corrective guidance.
• Support audit preparation and response from a clinical perspective.
• Partner with Case Management, UM leadership, Revenue Cycle, Compliance, and Operations.
• Provide insights and recommendations based on denial trends and utilization data.
• Participate in leadership discussions related to utilization strategy and risk mitigation.

Skills

Clinical judgment

Communication

Influence without authority

Decision-making

Business acumen

Payer criteria understanding

Education

MD/DO with valid license

Board Certified in specialty

Job description

Council Capital is seeking a physician leader to guide utilization management for our portfolio companies. You will serve as the primary physician resource for UM decision-making, medical necessity determinations, and complex case reviews.

This role requires collaboration with clinicians, payers, and internal teams to drive high-quality outcomes across multi-site healthcare services. The successful candidate will bring MD/DO licensure, board certification, and proven experience in utilization