Remote Medical Director - Utilization & Care Policy

CAI; Cheyenne (WY); Remoto; USD 234.000 - 276.000; Tempo pieno

Descrizione del lavoro

CAI is hiring a Medical Director to oversee utilization management with adherence to the highest clinical standards. This full-time remote role requires board-certified MD/DO credentials and at least five years of direct patient care experience, supported by strong communication and care-management skills.

Applicants should be licensed in at least one state (PA/NY/WV preferred) and ready to engage in multidisciplinary rounds, protocol development, and complex case reviews within a dynamic,

Competenze

• MD or DO required.
• Board Certification by ABMS or AOA.
• Active medical state licensure 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, including peer-to-peer discussions to determine medical necessity and appropriateness.
• Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned.
• Draft clear and concise rationales for member and provider notifications while adhering to compliance standards (NCQA, URAC, CMS, DOH, DOL).
• Ensure all aspects of medical management align with community standards of care.
• Participate as a CMDM multidisciplinary team member: attend huddles and grand rounds, and advise on cases requiring physician expertise.
• Contribute to protocol and guidelines development to ensure review process consistency.
• Actively manage projects or participate on teams that require physician SME.

Conoscenze

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Formazione

Master's Degree in Business Administration/Management or Public Health

Descrizione del lavoro

CAI is hiring a Medical Director to oversee utilization management with adherence to the highest clinical standards. This full-time remote role requires board-certified MD/DO credentials and at least five years of direct patient care experience, supported by strong communication and care-management skills.

Applicants should be licensed in at least one state (PA/NY/WV preferred) and ready to engage in multidisciplinary rounds, protocol development, and complex case reviews within a dynamic,