Remote Medical Director — Utilization Review Expert

Brighton Health Plan Solutions, LLC; Chapel Hill (NC); Remote; USD 180,000 - 260,000; Full time

Job summary

Brighton Health Plan Solutions, LLC is seeking a Medical Director to lead utilization review and medical necessity determinations for self-funded plans. The role supports the CMO and involves clinical decision-making, policy development, and accreditation support.

A physician with board certification and licensure is essential, with remote work flexibility. The position emphasizes peer discussions, appeals reviews, education delivery, and collaboration across committees to ensure quality,

Qualifications

• MD or DO degree with active, unrestricted state medical licensure; New York licensure required or obtainable.
• Current ABMS (or AOA equivalent) board certification, maintained throughout employment.
• Minimum 5 years of post-training clinical practice in an office, hospital, or academic setting.
• Minimum 2 years of utilization review or medical director experience at a health plan, TPA, managed care organization, or delegated medical group.
• Hands-on experience applying MCG or comparable evidence-based criteria and writing adverse determination rationale.

Responsibilities

• Renders medical necessity determinations across pre-service, concurrent, and post-service review within regulatory and contractual turnaround requirements.
• Applies MCG care guidelines, client-specific criteria, and BHPS medical policy consistently, documenting rationale defensible on appeal, external review, and audit.
• Conducts peer-to-peer discussions with attending physicians regarding admissions, continued stay, level of care, site of service, and contested coverage decisions.
• Reviews and adjudicates appeals for denied services in accordance with plan documents and applicable ERISA and state standards.
• Communicates certification decisions to nurse reviewers within required timeframes.
• Provides clinical input on member and provider grievances and reviews outcome with the Grievance Coordinator.
• Participates in long-length-of-stay rounds and complex case conferences to align decisions with the clinical course.
• Assists in developing medical policy and UM program documentation with the CMO.
• Serves as physician member of PCC, CPQC, UM, and Quality Committee as assigned.
• Supports URAC and NCQA accreditation activity and audits, including file review readiness.
• Delivers clinical education to reviewers and network providers on policy updates.
• Represents Medical Management in client-facing meetings with employers, brokers, and health-plan partners.

Skills

Clinical policy

URAC/NCQA knowledge

UR/ERISA understanding

Medical record review

Policy writing

Education

MD or DO degree

ABMS board certification

Tools

UM/EHR platforms

Microsoft Office

Excel/Tableau

Job description

Brighton Health Plan Solutions, LLC is seeking a Medical Director to lead utilization review and medical necessity determinations for self-funded plans. The role supports the CMO and involves clinical decision-making, policy development, and accreditation support.

A physician with board certification and licensure is essential, with remote work flexibility. The position emphasizes peer discussions, appeals reviews, education delivery, and collaboration across committees to ensure quality,