Remote Utilization Management Medical Director

SHPCA SCAN Health Plan; California (MO); Hybrid; USD 213,000 - 308,000; Full time

Benefits offered by this job

Robust Wellness Program

Generous PTO

Eleven paid holidays

401(k) Retirement Plan with employer 


Employee recognition program

Tuition reimbursement

Job summary

SCAN Health Plan is seeking a Utilization Management Physician Medical Director to provide physician-level clinical leadership for prior authorization, concurrent review, and appeals. The position requires active medical licensure and board certification in a relevant specialty, with strong experience in UM and managed care.

The role includes policy development, quality oversight, provider education, and collaboration with UM leadership.

Qualifications

• Graduate of an accredited medical school.
• MD/DO medical license in good standing.
• Active clinical practice for 5+ years.
• 2–3 years in utilization management or managed care.
• Familiarity with MCG criteria and NCQA/URAC CMS.

Responsibilities

• Perform physician-level medical necessity review of prior authorization, concurrent (inpatient) and retrospective reviews.
• Render determinations consistent with Medicare guidelines and evidence-based criteria.
• Conduct peer-to-peer discussions with attending physicians prior to adverse determinations.
• Serve as reviewer for first-level appeals and coordinate with external peer review when needed.
• Maintain availability for urgent/expedited reviews within required turnaround times.

Skills

Analytical skills

Leadership

Regulatory knowledge

Clinical decision-making

Peer-to-peer discussions

Education

Graduate of an accredited medical school

Tools

UM platforms

EHR systems

Job description

SCAN Health Plan is seeking a Utilization Management Physician Medical Director to provide physician-level clinical leadership for prior authorization, concurrent review, and appeals. The position requires active medical licensure and board certification in a relevant specialty, with strong experience in UM and managed care.

The role includes policy development, quality oversight, provider education, and collaboration with UM leadership.