Remote Medical Director - Utilization & Care Management

Confidential; Pittsburgh (Allegheny County); On-site; USD 180,000 - 240,000; Part time

Benefits offered by this job

Fully remote work environment

Job summary

Confidential is seeking a Medical Director to oversee utilization management within a multidisciplinary physician team. You will review escalated cases, evaluate medical necessity, and support appeals and grievances while shaping disease management initiatives.

You will provide physician leadership for policy development, protocol improvements, and regulatory compliance with NCQA, URAC, CMS, and other standards, including remote work and Eastern-friendly hours.

Qualifications

• MD or DO from an accredited medical school.
• Minimum of 5 years direct clinical patient care in hospital/outpatient/clinic.
• Board certification by ABMS or AOA.
• Active unrestricted medical license in PA, NY, or WV.
• At least 1 year in utilization management or payer-side care.
• Experience with medical necessity determinations and appeals preferred.

Responsibilities

• Conduct electronic utilization reviews to determine medical necessity.
• Perform initial determinations, appeals, and grievances as assigned.
• Lead telephonic peer-to-peer discussions with treating providers.
• Prepare clear clinical rationales and determination notifications.
• Ensure compliance with NCQA, URAC, CMS, DOH, and DOL standards.
• Collaborate with multidisciplinary teams on care management initiatives.
• Attend clinical huddles and interdisciplinary care discussions.
• Provide expertise on complex or high-risk cases.
• Develop and maintain utilization review protocols and guidelines.
• Support quality improvement and operational transformation initiatives.
• Maintain productivity with high daily case volumes.

Skills

Utilization management

Payer-side management

Clinical judgment

Communication skills

Documentation

Education

MD or DO degree

Tools

Predictal

Beacon

EMR systems

Job description

Confidential is seeking a Medical Director to oversee utilization management within a multidisciplinary physician team. You will review escalated cases, evaluate medical necessity, and support appeals and grievances while shaping disease management initiatives.

You will provide physician leadership for policy development, protocol improvements, and regulatory compliance with NCQA, URAC, CMS, and other standards, including remote work and Eastern-friendly hours.