Medical Director - Utilization Management

Medical Director – Utilization Management (Payer Side Experience Required)- (Remote)

Duration: 30 Weeks with possible extension Location: Pittsburgh, PA Schedule: Monday – Friday | 9:00 AM – 5:00 PM EST Core Hours: 40 Hours/Week Employment Type: Contract with Possibility of Full-Time Conversion Work Authorization: Must be a US Citizen

Position Overview

This role supports Utilization Management activities within a health insurance/payer environment and is responsible for conducting medical necessity reviews, appeals, and escalated case evaluations using established medical policy criteria. The Medical Director will collaborate with multidisciplinary teams and provide physician expertise on complex and high-risk cases while ensuring compliance with all applicable regulatory standards. The ideal candidate will have strong payer-side Utilization Management experience within a health insurance plan environment. Candidates whose experience is limited to hospital-side UM only may not be considered.

Responsibilities

• Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness of care.
• Perform initial determinations, appeals, grievances, and additional assigned utilization reviews.
• Participate in telephonic peer-to-peer discussions with providers as required.
• Prepare clear and concise clinical rationales for provider and member determinations.
• Ensure compliance with NCQA, URAC, CMS, DOH, DOL, and other regulatory standards.
• Participate as physician member of multidisciplinary care and disease management teams.
• Attend huddles, grand rounds, and provide physician expertise on high-risk or complex cases.
• Assist with protocol and guideline development to support review consistency.
• Participate in projects requiring physician subject matter expertise.
• Support initiatives focused on improving member care and clinical outcomes.

Required Qualifications

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
• Minimum 5 years of direct patient care experience (hospital, outpatient, or private practice)
• Board Certification in a specialty recognized by ABMS or AOA Specialty Certifying Boards
• Active unrestricted medical license in PA, NY, or WV
• Strong payer-side Utilization Management experience within a Health Insurance Plan
• Experience reviewing medical necessity determinations, appeals, and grievances
• Strong understanding of managed care and medical management processes
• Excellent oral and written communication skills
• Strong critical thinking and collaboration skills
• Comfortable conducting provider peer-to-peer reviews
• Proficiency with clinical software and general computer systems

Preferred Qualifications

• MBA or Master's Degree in Public Health
• Experience using MCG or InterQual guidelines
• Prior experience with Predictal and Beacon systems
• Managed care and payer-side case management experience

Additional Details

• Fully Remote opportunity
• Must complete Medical Director Assessment
• Expected productivity: 55+ cases per 8-hour day
• Systems used: Predictal and Beacon
• Beeline used for timesheets and onboarding
• Flexible scheduling after training completion

Candidate Categorization Requirement

Please categorize candidates in the submit form as one of the following:

• Non Behavioral Health (Physical Health)
  • Team requires approximately 10–11 hires
• Behavioral Health
  • Team requires approximately 1–2 hires
  • Open to part-time candidates

Important Client Feedback

The manager has indicated that many previously interviewed candidates lacked sufficient payer-side Utilization Management experience. Candidates with only hospital-side UM experience are generally not aligned with the team's needs. Preference will be given to candidates with direct health insurance plan / payer-side UM experience involving medical necessity reviews, appeals, grievances, and managed care operations.