Remote Medical Director - Utilization & Policy Excellence

CAI; Denver (CO); Remote; USD 350,000 - 420,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401k plan

Job summary

CAI is seeking a Medical Director for a fully remote, full-time role to ensure utilization management aligns with top clinical standards. You will lead medical policy reviews, determine medical necessity, and guide the CMDM team.

The position emphasizes physician expertise, protocol development, and cross-functional collaboration. Required are an MD/DO with board certification and active licenses in PA/NY/WV, plus 5+ years of direct patient care experience.

Qualifications

• Must hold MD or DO and be board-certified in a relevant specialty.
• Active medical license in PA, NY, or WV.
• At least 5 years of clinical, direct patient care experience.
• Experience with medical policy criteria and utilization management preferred.
• Strong critical thinking, communication, and collaboration skills.

Responsibilities

• Conduct electronic review of escalated cases against medical policy to determine medical necessity.
• Complete initial determination of cases, reviews of appeals and grievances.
• Write clear rationales for determinations in notifications, complying with NCQA, URAC, CMS, DOH, and DOL.
• Ensure medical management matches community standards of care.
• Participate in CMDM multidisciplinary team and advise on cases requiring physician expertise.
• Participate in protocol and guideline development.
• Manage projects requiring physician SME.

Skills

Clinical Skills

Critical Thinking

Case Management

Customer Service

Oral & Written Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Medical Policy Knowledge

Education

MD/DO

Board Certification

Job description

CAI is seeking a Medical Director for a fully remote, full-time role to ensure utilization management aligns with top clinical standards. You will lead medical policy reviews, determine medical necessity, and guide the CMDM team.

The position emphasizes physician expertise, protocol development, and cross-functional collaboration. Required are an MD/DO with board certification and active licenses in PA/NY/WV, plus 5+ years of direct patient care experience.