Remote Medical Director: Utilization Lead

CAI; Phoenix (AZ); Remote; USD 234,000 - 276,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401k retirement plan

Paid time off

Job summary

CAI is seeking a Medical Director to oversee utilization management, ensuring adherence to current clinical standards in a fully remote, full-time capacity across the United States.

The role requires an MD/DO with board certification and an active state license (PA/NY/WV preferred). You will lead reviews, author clear rationales, and collaborate with the CMDM team to enhance care quality and compliance.

Qualifications

• MD/DO degree with board certification.
• Active medical license in PA, NY, or WV.
• At least 5 years in direct clinical patient care.
• Strong skills in critical thinking, case management, communication, collaboration, and managed care.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness.
• Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned.
• Draft clear rationales for member/provider notifications adhering to NCQA, URAC, CMS, DOH, and DOL regulations.
• Ensure medical management aligns with community standards of care.
• Participate in CMDM multidisciplinary team: attend huddles and grand rounds and advise on physician-expert cases.
• Assist in protocol and guidelines development for consistency in reviews.
• Lead or participate in projects requiring physician subject matter expertise.

Skills

Clinical care

Critical thinking

Case management

Communication

Collaboration

Managed care

Education

MD/DO

Board certification

Active medical license

MBA/MPH (preferred)

Job description

CAI is seeking a Medical Director to oversee utilization management, ensuring adherence to current clinical standards in a fully remote, full-time capacity across the United States.

The role requires an MD/DO with board certification and an active state license (PA/NY/WV preferred). You will lead reviews, author clear rationales, and collaborate with the CMDM team to enhance care quality and compliance.