Remote Medical Director: Utilization Review & Policy

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

Job summary

Brighton Health Plan Solutions seeks a Medical Director to perform utilization review and medical necessity determinations for BHPS-administered self-funded commercial plans. You will support the Chief Medical Officer and oversee the clinical decisions that guide member care.

This remote role requires board-certified physicians with UR experience and strong policy interpretation skills, able to articulate defensible rationale under URAC and NCQA standards.

Qualifications

• MD/DO with active license and board-certified in an appropriate specialty.
• Minimum 5 years post-training clinical practice; UR/medical director experience preferred.
• Experience applying MCG or similar evidence-based criteria and writing determinations.

Responsibilities

• Renders medical necessity determinations across pre-service, concurrent, and post-service review.
• Applies client criteria and BHPS policy, documenting defensible rationale.
• Conducts peer-to-peer discussions with physicians on admissions and coverage decisions.
• Reviews and adjudicates appeals in compliance with ERISA and state standards.
• Provides clinical input on grievances and participates in case conferences.
• Mentors nurse reviewers and supports calibration across reviewers.
• Contributes to medical policy development and accreditation activities.

Skills

URAC/NCQA knowledge

Medical record review

Clinical policy interpretation

Clear rationale writing

Clinical judgment

Verbal/written communication

UM/EHR platforms

Education

MD/DO with active license

ABMS board certification

5+ years clinical practice

2+ years UR/medical director experience

Experience applying MCG criteria

Tools

UM platform experience

Job description

Brighton Health Plan Solutions seeks a Medical Director to perform utilization review and medical necessity determinations for BHPS-administered self-funded commercial plans. You will support the Chief Medical Officer and oversee the clinical decisions that guide member care.

This remote role requires board-certified physicians with UR experience and strong policy interpretation skills, able to articulate defensible rationale under URAC and NCQA standards.