Medical Director – Utilization Management

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

📋 Description

• Oversee physician responsibilities and make final decisions regarding outpatient utilization management activities, which include prior authorizations, retrospective reviews, and appeals.

• Ensure the medical necessity and appropriateness of outpatient services such as specialty referrals, diagnostics, imaging, durable medical equipment (DME), therapies, and procedures.

• Facilitate compliance with delegated health plan requirements, regulatory standards, and accreditation guidelines.

• Conduct peer-to-peer reviews and provide outpatient physician education to enhance documentation, adherence to guidelines, and appropriate utilization.

• Collaborate with Outpatient Medical Directors, Population Health, and UM nursing teams to synchronize utilization decisions with Astrana’s value-based care strategy.

• Recognize outpatient utilization trends, leakage, and variations; propose clinical strategies to enhance cost efficiency and quality outcomes.

• Act as a clinical liaison with health plans and external vendors regarding outpatient utilization management-related issues.

⛳️ Requirements

• MD or DO; Board Certified in Internal Medicine, Family Medicine, or a pertinent outpatient specialty is required.

• Active, unrestricted medical license (California required).

• Previous experience in outpatient utilization management, health plan medical management, or delegated risk environments.

• Strong comprehension of outpatient medical necessity criteria, prior authorization workflows, and appeals processes.

• Experience collaborating with primary care physicians (PCPs) and ambulatory specialists in value-based care models.

• Excellent physician-to-physician communication abilities and clinical judgment.

🏝️ Benefits

• This is a Remote - US based position.

• The national target base salary range for this role is: $250,000 - $325,000. Actual compensation will be determined based on geographic location (current or future), experience, or other job-related factors.

• Astrana Health is committed to being an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other legally protected characteristics. All employment decisions are made based on qualifications, merit, and business need. If you need assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.

Additional Information: The job description does not create an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and job requirements evolve.