Remote Medical Director, Utilization & Policy Review

CAI; Frankfort (KY); 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, ensuring compliance with current clinical standards. This full-time, remote role requires board-certified MD/DO with licensure in PA, NY or WV and at least 5 years of direct patient care.

You will review cases, draft rationales, and participate in multidisciplinary teams to guide medical decision-making while maintaining policy alignment with NCQA, URAC, CMS, and related regulations.

Qualifications

• MD/DO required and board-certified in a specialty recognized by ABMS or AOA
• Active medical state licensure for PA, NY, or WV
• Minimum 5 years in clinical direct patient care
• Strong skills in critical thinking, case management, communication, collaboration, listening and IT tools

Responsibilities

• Conduct electronic reviews 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
• Draft clear rationales for member and provider notifications while adhering to NCQA, URAC, CMS, DOH, and DOL standards
• Ensure medical management processes align with community standards of care
• Participate in CMDM multidisciplinary team and advise on cases needing physician expertise
• Contribute to protocol and guideline development for consistent review processes
• Lead or support projects requiring physician subject matter expertise

Skills

Critical Thinking

Case Management

Communication

Collaboration

Listening

Telephone Skills

General Computer Skills

Clinical Software

Managed Care

Education

MD/DO

Board Certification

Active State Licensure

Clinical Experience 5 Years

Tools

MCG/InterQual

Job description

CAI is seeking a Medical Director to oversee utilization management, ensuring compliance with current clinical standards. This full-time, remote role requires board-certified MD/DO with licensure in PA, NY or WV and at least 5 years of direct patient care.

You will review cases, draft rationales, and participate in multidisciplinary teams to guide medical decision-making while maintaining policy alignment with NCQA, URAC, CMS, and related regulations.