Remote Medical Director: Utilization & Clinical Policy

CAI; Augusta (ME); Remote; USD 234.000 - 276.000; Vollzeit

Benefits dieser Stelle

Medical, dental, vision benefits

401(k) retirement plan

Paid time off

Zusammenfassung

CAI is seeking a Medical Director to ensure utilization management aligns with high clinical standards. The role is full-time and remote, with eligibility for national coverage across multiple states.

Requirements include an MD or DO, board certification, active state licensure, and at least 5 years of direct patient care. The team collaborates on multidisciplinary reviews and develops protocols to guide care decisions.

Qualifikationen

• Must hold MD or DO with active medical licensure.
• Board certification in a specialty recognized by ABMS or AOA.
• Minimum 5 years in clinical direct patient care (hospital, outpatient, or private practice).
• Strong in clinical decision making, communication, and managed care concepts.

Aufgaben

• Perform electronic reviews of cases against medical policy criteria to determine medical necessity.
• Make initial determinations, review appeals and grievances, and handle other reviews as assigned.
• Draft clear rationales for notifications adhering to NCQA, URAC, CMS, DOH, and DOL regulations.

Kenntnisse

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Ausbildung

MD or DO

Board Certification (ABMS/AOA)

Tools

MCG or InterQual

Jobbeschreibung

CAI is seeking a Medical Director to ensure utilization management aligns with high clinical standards. The role is full-time and remote, with eligibility for national coverage across multiple states.

Requirements include an MD or DO, board certification, active state licensure, and at least 5 years of direct patient care. The team collaborates on multidisciplinary reviews and develops protocols to guide care decisions.