Medical Director, Utilization Review & Policy

brightonhealthplansolutions; Chapel Hill (NC); On-site; USD 180,000 - 240,000; Full time

Job summary

Brighton Health Plan Solutions is seeking a Medical Director to lead utilization review and medical necessity determinations for self-funded commercial plans. You will support the CMO, maintain clinical decision quality, and guide nurse reviewers with defensible documentation and policy interpretation.

In this role, you will engage in peer discussions with physicians, adjudicate appeals, and participate in accreditation activities while ensuring compliance with URAC, NCQA, ERISA, and state

Qualifications

• MD or DO with active, unrestricted state medical licensure.
• Current ABMS (or AOA) board certification maintained throughout employment.
• Minimum 5 years post-training clinical practice in office, hospital, or academic setting.
• Minimum 2 years of utilization review or medical director experience.

Responsibilities

• Renders medical necessity determinations across pre-, concurrent, and post-service reviews.
• Applies care guidelines and BHPS policy consistently with defensible rationale.
• Conducts peer-to-peer discussions with physicians on admissions and level of care.
• Reviews and adjudicates appeals for denied services under applicable standards.
• Communicates decisions to nurse reviewers within required timeframes.

Skills

Clinical leadership

URAC/NCQA knowledge

Medical policy interpretation

Communication with physicians

Documentation

Education

MD or DO with active license

ABMS board certification

5+ years clinical practice

2+ years utilization review

Experience applying MCG criteria

Tools

UM Platform

EHR software

MS Office

Job description

Brighton Health Plan Solutions is seeking a Medical Director to lead utilization review and medical necessity determinations for self-funded commercial plans. You will support the CMO, maintain clinical decision quality, and guide nurse reviewers with defensible documentation and policy interpretation.

In this role, you will engage in peer discussions with physicians, adjudicate appeals, and participate in accreditation activities while ensuring compliance with URAC, NCQA, ERISA, and state