Medical Director Utilization Management

Professional Job Description



Title: Medical Director Utilization Management



Job Type: 3 Months Contract
Location: Remote - CA



Shift: 8AM 5PM Mon Fri PST
Pay Range: XXXXXXXXXXX - XXXXXXXXXXX Per hr on w2.
Potential Extension or Conversion: Yes

Position Summary

We are seeking an experienced Medical Director to support the Utilization Management and Appeals function for commercial and Medicare lines of business. The Medical Director will provide clinical leadership in reviewing complex member appeals, determining medical necessity, evaluating quality-of-care grievances, and ensuring timely, consistent, and regulatory-compliant determinations.

Key Responsibilities

• Review and adjudicate complex member appeals and grievances involving medications, laboratory services, office visits, procedures, level of care, continuity of care, DME, and potentially investigational services.
• Apply clinical expertise, medical policies, state and federal regulations, and network requirements to make appropriate medical necessity and coverage determinations .
• Conduct and participate in peer-to-peer discussions with providers, IPA medical directors, and medical groups to resolve clinical issues.
• Support the Utilization Management (UM) and appeals process , ensuring decisions meet applicable regulatory and turnaround-time requirements.
• Review quality-of-care grievances and determine whether potential quality-of-care concerns exist.
• Collaborate with Pharmacy Services, Medical Policy, Legal, and other internal departments to provide clinical expertise.
• Evaluate appeals for both Commercial and Medicare populations.
• Support consistent application of clinical criteria, medical policies, and regulatory requirements across complex cases.
• Maintain accurate and timely documentation of clinical determinations and appeal outcomes.

Required Qualifications

• MD or DO degree from an accredited medical school.
• Completion of an accredited residency program, preferably in Internal Medicine, Family Medicine, or another adult primary care specialty .
• Active, unrestricted California Medical License.
• Board Certified or Board Eligible in an ABMS-recognized medical or surgical specialty.
• 5+ years of clinical experience , preferably in a managed care environment.
• 2+ years of Utilization Management and/or Concurrent, Prior-authorization, Post service reviews, Appeals Management experience.
• Experience with high-volume clinical reviews, appeals/grievances, regulatory compliance, and UM turnaround-time requirements .
• Strong knowledge of medical policy development and healthcare regulations.
• Experience working with Medicare populations and appeals processes preferred.
• Experience with NCQA or URAC-accredited health plans preferred.
• Strong analytical, organizational, communication, and decision-making skills.
• Proficiency with Microsoft Excel, Outlook, Word, and PowerPoint .