Remote Medical Director - Utilization Management Leader

CAI; Dover (DE); Remote; USD 234,000 - 276,000; Full time

Job summary

CAI is seeking a Medical Director to oversee utilization management in line with current clinical standards. This full-time remote role requires leadership in a multidisciplinary setting and accountability for medical policy adherence.

You will conduct electronic reviews, determine medical necessity, and provide clear rationales for determinations while collaborating with physician peers and adhering to regulatory standards (NCQA, URAC, CMS, DOH, DOL).

Qualifications

• 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice).
• MD/DO degree and board certification as required.
• Active medical state licensure for PA, NY, or WV.

Responsibilities

• 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.
• Compose clear rationales for member and provider determinations while complying with NCQA, URAC, CMS, DOH, and DOL regulations.
• Ensure all aspects of medical management align with community standards of care.
• Participate on CMDM multidisciplinary team and advise on cases needing physician input.
• Participate in protocol and guidelines development for review consistency.
• Manage projects or participate in teams requiring physician expertise.

Skills

Critical Thinking

Case Management

Communication

Collaboration

Managed Care

Clinical Software

Telephone Skills

General Computer Skills

Education

MD/DO

Board Certification (ABMS/AOA)

Tools

MCG/InterQual

Job description

CAI is seeking a Medical Director to oversee utilization management in line with current clinical standards. This full-time remote role requires leadership in a multidisciplinary setting and accountability for medical policy adherence.

You will conduct electronic reviews, determine medical necessity, and provide clear rationales for determinations while collaborating with physician peers and adhering to regulatory standards (NCQA, URAC, CMS, DOH, DOL).