Remote Medical Director, Utilization Management

ISHE; San Antonio, Northern (TX, KY); Hybrid; USD 249,000 - 373,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Job summary

WellMed, part of the Optum family, seeks a Medical Director for Utilization Management to lead and optimize our UM program. This role focuses on medical necessity, CMS criteria, and program improvements while fostering a collaborative, remote-friendly work environment across the U.S.

You will drive utilization management initiatives, monitor trends, and provide guidance to physicians and staff to ensure compliant, high-quality patient care.

Qualifications

• MD/DO/MBBS degree required
• Board certification in Family Medicine, Internal Medicine, or Emergency Medicine
• Active, unrestricted medical license in any state
• 5+ years of post-residency clinic practice experience
• Proficiency with Microsoft Office applications
• Bilingual English/Spanish preferred

Responsibilities

• Develop and maintain an efficient Utilization Management program for health plan members
• Stay current with CMS criteria hierarchy and organizational determination processes
• Participate in case reviews and medical necessity determinations
• Ensure compliance with CMS and delegated health plans regulations
• Conduct post-service reviews for medical necessity and benefit determination coding
• Develop medical management, care management, and utilization management protocols
• Attend physician meetings and orient new physicians to policies and resources
• Support growth and development of staff within the UM department
• Provide education on medical technologies, review criteria, and UM policies

Skills

Bilingual English/Spanish

MS Office proficiency

Education

MD/DO/MBBS

Active unrestricted medical license

Job description

WellMed, part of the Optum family, seeks a Medical Director for Utilization Management to lead and optimize our UM program. This role focuses on medical necessity, CMS criteria, and program improvements while fostering a collaborative, remote-friendly work environment across the U.S.

You will drive utilization management initiatives, monitor trends, and provide guidance to physicians and staff to ensure compliant, high-quality patient care.