Remote Medical Director - Utilization Management

Confidential; Pittsburgh (Allegheny County); On-site; USD 180,000 - 240,000; Full time

Benefits offered by this job

Fully remote work environment

Job summary

Confidential in the United States is seeking a Medical Director to lead utilization management activities and support clinical policy development. You will review escalated cases, determine medical necessity, and assist with appeals and grievances while guiding disease management and regulatory compliance initiatives.

You will participate in multidisciplinary teams, conduct peer-to-peer reviews, and provide expert clinical rationale for complex decisions within a remote, high-volume environment.

Qualifications

• MD/DO degree from an accredited institution.
• Board certification in an ABMS or AOA recognized specialty.
• Active unrestricted medical license in PA/NY/WV or equivalent.

Responsibilities

• Conduct electronic utilization reviews of escalated cases to determine medical necessity.
• Perform initial determinations, appeals, grievances, and case reviews.
• Conduct telephonic peer-to-peer discussions with treating providers.
• Prepare clear, compliant clinical rationales and determination notifications.
• Ensure compliance with NCQA, URAC, CMS, DOH, DOL and other standards.
• Participate as physician lead in multidisciplinary care teams and huddles.
• Assist in development and maintenance of utilization review protocols and guidelines.

Skills

Utilization management

Clinical policy

Peer-to-peer reviews

Regulatory compliance

Communication skills

EMR systems

Education

MD/DO

ABMS/AOA board certification

US medical license

Tools

Predictal

Beacon

Job description

Confidential in the United States is seeking a Medical Director to lead utilization management activities and support clinical policy development. You will review escalated cases, determine medical necessity, and assist with appeals and grievances while guiding disease management and regulatory compliance initiatives.

You will participate in multidisciplinary teams, conduct peer-to-peer reviews, and provide expert clinical rationale for complex decisions within a remote, high-volume environment.