Remote Medical Director, Utilization Management

CAI; Santa Fe (NM); Remote; USD 234,000 - 276,000; Full time

Job summary

CAI is seeking a Medical Director for a remote, full-time role to oversee utilization management in accordance with current clinical standards. The candidate will perform electronic reviews, determine medical necessity, and guide case determinations with a focus on adherence to regulatory guidelines.

Required are an MD or DO with active licensure, board certification, and at least 5 years of clinical practice experience.

Qualifications

• MD or DO with active medical licensure
• Board certification in a specialty recognized by ABMS or AOA
• 5 years in clinical, direct patient care (hospital, outpatient, or private practice)
• Strong skills in critical thinking, case management, customer service, oral & written communication, collaboration, listening, and general computer skills

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
• Compose clear rationales for notifications while adhering to compliance standards (NCQA, URAC, CMS, DOH, and DOL)
• Ensure medical management processes align with community standards of care
• Participate in CMDM multidisciplinary team meetings and advise on cases requiring physician expertise
• Contribute to protocol and guideline development for review consistency
• Lead or participate in projects that require physician SME involvement

Skills

Clinical expertise

Critical thinking

Communication

Team collaboration

Medical policy

Education

MD or DO

Board Certification

Job description

CAI is seeking a Medical Director for a remote, full-time role to oversee utilization management in accordance with current clinical standards. The candidate will perform electronic reviews, determine medical necessity, and guide case determinations with a focus on adherence to regulatory guidelines.

Required are an MD or DO with active licensure, board certification, and at least 5 years of clinical practice experience.