Remote Medical Director – Utilization Management

CAI; Boise (ID); Remoto; USD 234.000 - 276.000; Tempo pieno

Descrizione del lavoro

CAI is seeking a Medical Director to lead utilization management, ensuring care aligns with the highest clinical standards. This full-time, remote role supports our Boise, Idaho operations.

You will review cases, determine medical necessity, draft determinations, participate in multidisciplinary rounds, and help develop protocols. MD/DO required with board certification and active licensure; 5 years of direct patient care experience.

Competenze

• Medical Doctor (MD) or DO required.
• Board Certification by ABMS or AOA required.
• Active medical state licensure for PA, NY, or WV.
• Minimum 5 years of clinical direct patient care experience.
• Strong skills in critical thinking, case management, customer service, communication, collaboration, listening, and basic computer and clinical software proficiency.

Mansioni

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity.
• Complete initial determination of cases, review appeals and grievances, and other reviews as assigned.
• Draft clear rationales for member/provider determinations adhering to NCQA, URAC, CMS, DOH, and DOL rules.
• Ensure medical management aligns with community standards of care.
• Participate in CMDM multidisciplinary team and advise on cases needing physician input.
• Contribute to protocol and guideline development for consistent review.
• Lead or participate in projects requiring physician SME.

Conoscenze

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Formazione

MD/DO degree

Board Certification

Master’s in MBA/Public Health

Strumenti

MCG/InterQual

Descrizione del lavoro

CAI is seeking a Medical Director to lead utilization management, ensuring care aligns with the highest clinical standards. This full-time, remote role supports our Boise, Idaho operations.

You will review cases, determine medical necessity, draft determinations, participate in multidisciplinary rounds, and help develop protocols. MD/DO required with board certification and active licensure; 5 years of direct patient care experience.