Remote Utilization Management Medical Director

medix; New York (NY); Remote; USD 180,000 - 230,000; Full time

Job summary

medix is partnering with a large national health plan to hire an experienced Utilization Management Medical Director for a fully remote opportunity in the United States. This contract-to-hire role offers flexibility, leadership potential, and the chance to influence medical necessity decisions across a payer network.

The incumbent will conduct medical necessity reviews, manage prior authorizations, and participate in appeals, while ensuring compliance with NCQA, CMS, URAC, and evolving

Qualifications

• MD or DO degree required and board certified.
• Active, unrestricted medical license with at least one state license (PA/NY/WV).
• Multiple years of payer-side utilization management experience as Medical Director.
• Direct health plan utilization review experience.
• Strong knowledge of managed care operations and medical necessity criteria.
• Ability to work independently in a remote production environment.

Responsibilities

• Conduct medical necessity and utilization management reviews.
• Review escalated cases using established medical policies and clinical criteria.
• Complete prior authorization reviews.
• Support appeals and grievance determinations.
• Participate in peer-to-peer discussions with treating providers.
• Ensure compliance with NCQA, CMS, URAC, and regulatory requirements.
• Provide clinical expertise on complex utilization management cases.
• Collaborate with clinical and operational leadership teams.

Skills

Payer-side UM experience

Remote work independence

Medical necessity criteria knowledge

Independent in remote production

Education

MD or DO

Tools

Active medical license

State licensure: PA, NY, WV

InterQual/MCG criteria knowledge

Payer-side utilization management

Job description

medix is partnering with a large national health plan to hire an experienced Utilization Management Medical Director for a fully remote opportunity in the United States. This contract-to-hire role offers flexibility, leadership potential, and the chance to influence medical necessity decisions across a payer network.

The incumbent will conduct medical necessity reviews, manage prior authorizations, and participate in appeals, while ensuring compliance with NCQA, CMS, URAC, and evolving