Remote Medical Director, Utilization and Policy Oversight

CAI; San Juan (PR); Remote; USD 234,000 - 276,000; Full time

Job summary

CAI is seeking a Medical Director to oversee utilization management, ensuring adherence to the highest clinical standards. This full-time, remote role requires board-certified MD/DO with active state licensure and 5+ years of direct patient care, plus strong communication and clinical software skills.

You will contribute to protocol development, participate in multidisciplinary rounds, and supervise complex reviews from home while aligning with regulatory standards.

Qualifications

• MD or DO with active medical state licensure for PA, NY, or WV
• Board certification in an ABMS/AOA-recognized specialty
• 5 years in clinical, direct patient care (hospital, outpatient, or private practice)
• Strong skills in critical thinking, case management, customer service, oral & written communication, collaboration, listening, telephone skills, general computer skills, clinical software, and managed care

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria, including possible telephonic peer-to-peer discussions
• Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned
• Draft clear, concise rationales for member and provider notifications while complying with NCQA/URAC/CMS/DOH/DOL rules
• Ensure medical management aligns with community standards of care
• Participate on the CMDM multidisciplinary team, attend huddles and grand rounds, and advise on cases needing physician input
• Assist in protocol and guidelines development for consistency in review processes
• Actively manage projects or participate on teams requiring physician subject matter expertise

Skills

Critical Thinking

Case Management

Customer Service

Oral Communication

Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

Medical degree (MD/DO)

Board Certification

Tools

MCG or InterQual

Job description

CAI is seeking a Medical Director to oversee utilization management, ensuring adherence to the highest clinical standards. This full-time, remote role requires board-certified MD/DO with active state licensure and 5+ years of direct patient care, plus strong communication and clinical software skills.

You will contribute to protocol development, participate in multidisciplinary rounds, and supervise complex reviews from home while aligning with regulatory standards.