Remote Medical Director, Utilization & Policy Leadership

CAI; Richmond (VA); À distance; USD 234 000 - 276 000; Plein temps

Résumé du poste

CAI is seeking a Medical Director to lead utilization management with a focus on clinical standards and peer review. The role is full‑time and remote, offering exposure to NCQA, URAC, CMS, and other regulatory frameworks.

The position requires an MD/DO, board certification, active state licensure (PA/NY/WV), and at least five years in direct patient care, with strong communication and managed care knowledge. Remote work supports flexible collaboration.

Qualifications

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)

Responsabilités

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity
• Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned
• Compose clear and concise rationales for members and provider determinations while adhering to NCQA, URAC, CMS, DOH, and DOL regulations
• Ensure that all aspects of the medical management process are consistent with community standards of care
• Participate as a member of the CMDM multidisciplinary team: attend huddles and grand rounds, and advise the multidisciplinary team on cases requiring physician expertise
• Participate in protocol and guidelines development to ensure consistency in the review process
• Actively manage projects and/or participate on project teams that require a physician subject matter expert

Connaissances

Critical Thinking

Case Management

Customer Service

Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Description du poste

CAI is seeking a Medical Director to lead utilization management with a focus on clinical standards and peer review. The role is full‑time and remote, offering exposure to NCQA, URAC, CMS, and other regulatory frameworks.

The position requires an MD/DO, board certification, active state licensure (PA/NY/WV), and at least five years in direct patient care, with strong communication and managed care knowledge. Remote work supports flexible collaboration.