Remote Medical Director: Utilization & Policy Lead

CAI; Lansing (MI); Remote; USD 234,000 - 276,000; Full time

Benefits offered by this job

Remote work

Job summary

CAI is seeking a Medical Director to ensure utilization management aligns with top clinical standards. This full‑time remote role requires MD/DO, board certification, and active licensure in PA/NY/WV, with 5+ years clinical experience.

You will participate in multidisciplinary teams, develop guidelines, and manage reviews, with emphasis on compliance and quality care in a remote setting.

Qualifications

• MD or DO with board certification in a recognized specialty.
• Active state medical licensure required for PA, NY or WV.
• Minimum 5 years in clinical direct patient care.
• Strong critical thinking, case management and communication skills.

Responsibilities

• Conduct electronic reviews to determine medical necessity per policy.
• Handle initial determinations, appeals and grievances as assigned.
• Draft clear rationales for notifications adhering to NCQA, URAC, CMS, DOH and DOL rules.
• Ensure medical management aligns with community standards of care.
• Participate in CMDM rounds, huddles and advise on physician cases.
• Contribute to protocol and guideline development for review consistency.
• Lead or join projects requiring physician SME 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 (ABMS or AOA)

Active medical state licensure

Master's in Business Administration/Management or Public Health

Job description

CAI is seeking a Medical Director to ensure utilization management aligns with top clinical standards. This full‑time remote role requires MD/DO, board certification, and active licensure in PA/NY/WV, with 5+ years clinical experience.

You will participate in multidisciplinary teams, develop guidelines, and manage reviews, with emphasis on compliance and quality care in a remote setting.