Remote Medical Director: Utilization & Care Management

CAI; Carson City (NV); Remote; USD 234,000 - 276,000; Full time

Benefits offered by this job

Remote work

Job summary

CAI is seeking a Medical Director to oversee utilization management, ensuring compliance with the highest clinical standards. This full-time, remote position requires physician leadership to support reviews and policy adherence.

The role emphasizes collaboration with CMDM, protocol development, and project leadership across cases, appeals, and determinations within a virtual work environment.

Qualifications

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
• Board Certification in a specialty recognized by ABMS or AOA
• Active medical state licensure required for PA, NY, or WV
• 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, determining 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 determination notifications adhering to NCQA, URAC, CMS, DOH, and DOL regulations
• Ensure all aspects of the medical management process align with community standards of care
• Participate as a CMDM multidisciplinary team member, attend huddles and grand rounds, advise on cases needing physician input
• Participate in protocol and guidelines development for consistency in review process
• Actively manage projects or participate on teams requiring physician SME

Skills

Critical Thinking

Case Management

Customer Service

Oral Communication

Written Communication

Collaboration

Listening

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO degree

Board Certification

Active state licensure (PA/NY/WV)

Tools

Remote work tools

Job description

CAI is seeking a Medical Director to oversee utilization management, ensuring compliance with the highest clinical standards. This full-time, remote position requires physician leadership to support reviews and policy adherence.

The role emphasizes collaboration with CMDM, protocol development, and project leadership across cases, appeals, and determinations within a virtual work environment.