Remote Medical Director: Utilization & Clinical Strategy

CAI; Trenton (NJ); Remote; USD 234,000 - 276,000; Full time

Job summary

CAI is seeking a Medical Director to lead utilization management initiatives remotely in the United States. This role requires an MD or DO, board certification, and active licensure; you will guide clinical reviews, policy adherence, and multidisciplinary collaboration.

As a full-time remote position, you will influence care standards, participate in protocol development, and support a network across the organization with a focus on quality and compliance.

Qualifications

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
• Board Certification recognized by ABMS or AOA
• Active state medical licensure for PA, NY, or WV
• 5 years of clinical, direct patient care experience
• Strong skills in critical thinking, case management, customer service, oral and written communication, collaboration, listening, and general computer skills

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity
• Complete initial determination of cases, review of appeals and grievances, and other reviews
• Compose clear rationales for member and provider determination notifications per compliance standards (NCQA, URAC, CMS, DOH, DOL)
• Ensure medical management processes align with community standards of care
• Participate in CMDM multidisciplinary team meetings and advise on physician-expert cases
• Develop protocols and guidelines to ensure consistency in review processes
• Lead or participate in projects requiring physician subject-matter expertise

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Medical Management in Health Insurance

MCG InterQual

Education

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

Job description

CAI is seeking a Medical Director to lead utilization management initiatives remotely in the United States. This role requires an MD or DO, board certification, and active licensure; you will guide clinical reviews, policy adherence, and multidisciplinary collaboration.

As a full-time remote position, you will influence care standards, participate in protocol development, and support a network across the organization with a focus on quality and compliance.