Part-Time Medical Director of Utilization Management

Mascmedical; California; 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 you will own medical necessity determinations across outpatient, inpatient, and post-acute settings.

You will lead peer-to-peer discussions, oversee the appeals process under CMS, Medi-Cal, and PACE requirements, and collaborate with interdisciplinary teams to drive

Qualifications

• Active, unrestricted California MD or DO license.
• Active DEA registration.
• Current BLS.
• Board certified or board eligible in a primary care specialty.
• 5+ years of clinical practice in Internal Medicine, Geriatrics, and/or Family Medicine.
• 3+ years in utilization/resource management or medical leadership within managed care, a health plan, or a value-based care setting.
• Working command of Medicare and Medicaid/Medi-Cal regulations and CMS coverage criteria.
• Experience applying evidence-based UM guidelines (InterQual preferred; MCG acceptable).

Responsibilities

• Make and direct medical necessity determinations for outpatient, inpatient, and post-acute care (SNF, ALF, LTACH, palliative, hospice, home health).
• Apply InterQual and CMS coverage criteria; own the standards and train the team on how to use them.
• Lead peer-to-peer discussions with site medical directors, PCPs, and external network and non-contracted 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 requirements.
• Support authorization review, concurrent review, and denial management alongside nurse UM specialists.
• Monitor for over- and under-utilization; spot patterns driving avoidable admissions and length-of-stay.
• Provide oversight of HCC/ICD-10 diagnosis coding and RAF accuracy.
• Develop medical policy and drive evidence-based clinical guideline adoption.
• Partner with the CMO, Behavioral Health Director, Health Plan Director, and interdisciplinary teams.
• Chair or sit on committees including credentialing and P&T.
• Document to PACE, NCQA, and CMS standards and support audit readiness.

Skills

Utilization management

Clinical leadership

CMS/Medi-Cal knowledge

InterQual guidelines

Policy development

Peer discussions

Education

California MD or DO license

DEA registration

BLS certification

Board certification or eligibility (primary care)

5+ years clinical practice (Internal Medicine/Geriatrics/Family Medicine)

3+ years in utilization/resource management or medical leadership

Tools

InterQual/MCG guidelines

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 you will own medical necessity determinations across outpatient, inpatient, and post-acute settings.

You will lead peer-to-peer discussions, oversee the appeals process under CMS, Medi-Cal, and PACE requirements, and collaborate with interdisciplinary teams to drive