Remote Medical Director, Utilization and Clinical Policy

CAI; Juneau (AK); Remote; USD 234,000 - 276,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

401(k)

Paid Time Off

Job summary

CAI is seeking a Medical Director to oversee utilization management under strict clinical standards. This fully remote, full‑time position requires a medical degree, board certification, and active licensure in PA, NY, or WV.

You will lead reviews, ensure policy alignment, and guide care decisions within a multidisciplinary CMDM team. The role emphasizes compliance with NCQA, URAC, CMS, and DOH guidelines, with opportunities to shape protocols and drive high‑quality patient care across the

Qualifications

• MD/DO degree required.
• Board certification in ABMS or AOA recognized specialty.
• Active medical license in PA, NY or WV.
• Minimum 5 years of clinical/direct patient care experience.
• Strong communication and analytical skills.
• Experience with managed care concepts.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned.
• Compose clear and concise rationales for members and provider determinations while adhering to compliance standards (NCQA, URAC, CMS, DOH, and DOL).
• Ensure medical management activities align with community standards of care.
• Participate as a CMDM multidisciplinary team member; attend huddles and grand rounds and advise on cases needing physician input.
• Participate in protocol and guideline development to ensure consistency in reviews.
• Actively manage projects or join project teams requiring physician SME.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

ABMS/AOA Board Certification

Active medical license (PA/NY/WV)

Tools

MCG

InterQual

Job description

CAI is seeking a Medical Director to oversee utilization management under strict clinical standards. This fully remote, full‑time position requires a medical degree, board certification, and active licensure in PA, NY, or WV.

You will lead reviews, ensure policy alignment, and guide care decisions within a multidisciplinary CMDM team. The role emphasizes compliance with NCQA, URAC, CMS, and DOH guidelines, with opportunities to shape protocols and drive high‑quality patient care across the