Director of Utilization Management

You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.

Job Summary

Our client is seeking a Director of Utilization Management to conduct utilization management reviews and ensure compliance with medical policy criteria. The role involves collaborating with leadership teams, providing clinical expertise, and supporting appeals and grievances processes.

Key Responsibilities

• Conduct utilization management reviews for medical necessity and appropriateness of care.
• Review escalated cases using established medical policy criteria.
• Participate in peer-to-peer discussions with providers as needed.
• Support appeals, grievances, and prior authorization reviews.
• Ensure compliance with NCQA, CMS, URAC, and applicable regulatory standards.
• Collaborate with operational and clinical leadership teams to support efficient review processes.
• Provide clinical expertise and guidance on complex cases.

Qualifications

• MD or DO.
• Board Certified.
• Active unrestricted medical license.
• Multiple years of payer-side / health insurance utilization management experience as a Medical Director at a Health Plan.
• Experience conducting utilization review within a health plan environment.
• Strong understanding of managed care operations and medical necessity criteria.
• Ability to work independently in a remote production environment.

Experience

• Medicare Advantage and/or Commercial plan experience.
• Appeals and grievance review experience.
• Prior authorization review experience.
• Peer-to-peer review experience.
• Multi-state licensure.

Additional Requirements

40 hours per week schedule. Flexible, typical hours 8:30 AM - 5:00 PM.

Benefits

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
• Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
• 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
• Short Term Disability Insurance.
• Term Life Insurance Plan.

Required Employment / Compliance Language

As an Equal Opportunity Employer, Medix is committed to providing a safe and inclusive working environment for all employees.

* We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).


Medix Overview:

With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we're dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.

Any required state or Joint Commission training is compensated at the state or local minimum wage rate.

* As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient's residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.