Lead Medical Director, Utilization Management

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess all outpatient referrals and direct inpatient admissions for medical suitability.

• Complete assigned prior authorizations, concurrent reviews, retrospective analyses, and other utilization management cases within defined turnaround times.

• Ensure that clinical decisions are in accordance with relevant medical necessity standards and uphold the clinical integrity of UM evaluations.

• Oversee a team of Utilization Management Medical Directors.

• Examine complex or escalated cases and seek specialty consultation as necessary.

• Create, review, and uphold clinical policies, pharmacy guidelines, medical necessity criteria, and UM procedures.

• Track emerging evidence and propose updates to policies.

• Lead the Utilization Management Committee, including setting agendas, making policy recommendations, analyzing utilization trends, and ensuring follow-through on decisions.

• Participate in the Credentialing Committee, providing insights on credentialing issues, provider qualifications, and clinical matters.

• Contribute to the Quality Committee by spotting trends and suggesting enhancements.

• Engage in peer-to-peer discussions, appeals, and provider education initiatives.

• Utilize audits, case evaluations, appeals, complaints, and UM performance metrics to enhance policies, clinical practices, and workflows.

• Collaborate with care management, quality, compliance, network, pharmacy, and operations teams.

• Facilitate regulatory and accreditation preparedness through clinical documentation, committee records, and corrective actions.

• Provide guidance to organizational leaders on UM strategy, clinical risks, and the experiences of members and providers.

• Acquire knowledge of UM policies, workflows, committee processes, and documentation requirements within the first 90 days.

• Consistently perform reviews, contribute to committee activities, and identify trends in cases or policies within the first 6 months.

• Promote clear policies, consistent clinical decisions, committee accountability, and measurable enhancements in quality, access, or outcomes over time.

⛳️ Requirements

• MD or DO degree with an active, unrestricted medical license.

• Board certification in a relevant clinical specialty.

• Minimum of 5 years of clinical practice experience in utilization management or medical necessity assessments.

• At least 5 years of leadership experience directly managing a clinical team.

• Knowledge of evidence-based guidelines, coverage policies, quality improvement, and relevant regulatory and accreditation standards.

• Strong clinical judgment, effective communication skills, conflict resolution abilities, and capacity to contribute meaningfully in committee settings.

🏝️ Benefits

• Competitive base salary.

• Equity opportunities.

• Performance-based bonus program.

• 401k matching.

• Regular compensation reviews.

• Comprehensive medical, dental, and vision coverage.

• No-Meeting Fridays.

• Monthly company holidays.

• Mental health resources.

• Generous flexible time-off policy.

• Remote-first culture supporting collaboration and flexibility.

• Learning programs.

• Mentorship.

• Professional development funding.

• Regular performance feedback and reviews.

• Employee Stock Purchase Plan (ESPP) providing discounted equity opportunities.

• Reimbursement for home office setup expenses.

• Monthly cell phone and internet stipend.

• Paid parental leave for all new parents.