Remote Medical Director: Utilization & Care Management

CAI; Austin (TX); Remoto; USD 234.000 - 276.000; Tempo pieno

Vantaggi offerti da questo lavoro

Medical, dental, and vision insurance

401k retirement account access

Paid sick leave or PTO

Descrizione del lavoro

CAI is seeking a Medical Director to ensure utilization management is performed per current clinical standards. This full-time, remote role requires leadership in medical reviews, policy adherence, and collaboration with the CMDM team.

Responsibilities include case determinations, appeals reviews, and drafting rationales compliant with NCQA, URAC, CMS, DOH, and DOL standards. Ideal candidates hold MD/DO, board certification, and licensure in relevant states.

Competenze

• MD or DO medical degree.
• Board certification by ABMS or AOA.
• Active medical state licensure required for PA, NY, or WV.
• 5 years in clinical direct patient care.
• Strong skills in Critical Thinking, Case Management, Customer Service, Oral & Written Communication, Collaboration, Listening, Telephone Skills, General Computer Skills, Clinical Software, and Managed Care.

Mansioni

• 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.
• Draft clear, concise rationales for members and provider determinations while adhering to compliance standards (NCQA, URAC, CMS, DOH, and DOL).
• Ensure medical management aligns with community standards of care.
• Participate in CMDM multidisciplinary team; attend huddles and grand rounds, advising on cases needing physician input.
• Assist in protocol and guidelines development for consistency in the review process.
• Actively manage projects or participate on project teams requiring physician SME.

Conoscenze

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Formazione

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)

Board Certification by ABMS or AOA

Strumenti

MCG

InterQual

Descrizione del lavoro

CAI is seeking a Medical Director to ensure utilization management is performed per current clinical standards. This full-time, remote role requires leadership in medical reviews, policy adherence, and collaboration with the CMDM team.

Responsibilities include case determinations, appeals reviews, and drafting rationales compliant with NCQA, URAC, CMS, DOH, and DOL standards. Ideal candidates hold MD/DO, board certification, and licensure in relevant states.