Remote Medical Director, Utilization Management

CAI; Madison (WI); Remote; USD 234,000 - 276,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401k retirement plan

Job summary

CAI is seeking a Medical Director to lead utilization management with adherence to the highest clinical standards. This remote, full‑time role demands physician expertise and collaboration with multidisciplinary teams to ensure compliant medical decision‑making.

Requirements include an MD/DO, board certification, active state licensure (PA/NY/WV), and at least 5 years in direct patient care. Strong communication and managed care knowledge are essential.

Qualifications

• MD or DO medical degree required
• Board certification by ABMS or AOA
• Active medical license in PA, NY, or WV
• 5 years clinical direct patient care experience
• 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
• Complete initial determinations, reviews of appeals and grievances, and other reviews
• Draft clear, concise rationales for member and provider determinations per compliance standards (NCQA, URAC, CMS, DOH, DOL)
• Ensure all medical management processes align with community standards of care
• Participate in CMDM multidisciplinary team meetings and advise on physician-expert cases
• Contribute to protocol and guideline development for review consistency
• Lead or join projects requiring physician subject-matter expertise

Skills

Critical thinking

Case management

Communication

Collaboration

Listening

Telephone skills

Education

Master's in Business Administration

Master's in Public Health

Medical degree (MD/DO)

Tools

Clinical software

Job description

CAI is seeking a Medical Director to lead utilization management with adherence to the highest clinical standards. This remote, full‑time role demands physician expertise and collaboration with multidisciplinary teams to ensure compliant medical decision‑making.

Requirements include an MD/DO, board certification, active state licensure (PA/NY/WV), and at least 5 years in direct patient care. Strong communication and managed care knowledge are essential.