Remote Medical Director - Utilization Management Leader

CAI; Lincoln (NE); Remote; USD 234,000 - 276,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

401k

Paid Time Off

Job summary

CAI is seeking a Medical Director to oversee utilization management with a focus on clinical standards. The role is full-time and remote, offering the flexibility to impact care across the organization.

The ideal candidate will hold an MD/DO, board certification, and licensure in at least one state, with 5+ years of direct patient care experience. The position emphasizes adherence to compliance standards, collaboration with the CMDM team, and participation in protocol development while

Qualifications

• MD or DO degree with medical licensure required.
• Board certification in a recognized ABMS or AOA specialty.
• Active medical state licensure required for PA, NY, or WV.
• At least 5 years in clinical direct patient care.
• Strong skills in communication, case management, and managed care.

Responsibilities

• Perform electronic reviews to determine medical necessity against policy.
• Manage initial determinations, appeals, grievances and other reviews.
• Draft clear rationales for notifications in compliance with NCQA, URAC, CMS, DOH, DOL.
• Align medical management with community standards of care.
• Participate in CMDM multidisciplinary team and advise on cases needing physician expertise.
• Contribute to protocol and guideline development.
• Lead or join projects requiring physician subject matter expertise.

Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

Board Certification

Active State Licensure (PA/NY/WV)

MBA/MPH preferred

Tools

MCG

InterQual

Job description

CAI is seeking a Medical Director to oversee utilization management with a focus on clinical standards. The role is full-time and remote, offering the flexibility to impact care across the organization.

The ideal candidate will hold an MD/DO, board certification, and licensure in at least one state, with 5+ years of direct patient care experience. The position emphasizes adherence to compliance standards, collaboration with the CMDM team, and participation in protocol development while