Medical Director - Utilization Management (MD/DO) - Part Time

Job Description

Job Description

Medical Director, Utilization Management (MD/DO) – Part Time

Pay: $139.23 – $189.38 per hour — roughly $145,000–$197,000 a year for a 20-hour week Schedule: Part-time, 20 hours per week Location: San Diego, CA License: Active, unrestricted California MD or DO + DEA + BLS

MASC Medical is recruiting a part-time Medical Director of Utilization Management for a San Diego PACE program (Program of All-Inclusive Care for the Elderly) serving frail, dual-eligible older adults.

This is a 20-hour-a-week physician leadership role with no patient panel and no call. You'd own medical necessity determinations across outpatient, inpatient, and post-acute settings, run peer-to-peer conversations, and lead the appeals process — the clinical judgment part of the job, without the RVU treadmill. It's built for an internist or geriatrician who has done the clinical years and wants to influence how care gets delivered for a whole population instead of one patient at a time.

What you'll do

• Make and direct medical necessity determinations for outpatient, inpatient, and post-acute care (SNF, ALF, LTACH, palliative, hospice, home health)
  

• Apply InterQual and CMS coverage criteria; own the standards and train the team on how to use them
  

• Lead peer-to-peer discussions with site medical directors, PCPs, and external network and non-contracted providers
  

• Serve as physician reviewer on escalated and complex utilization cases
  

• Lead and protect the integrity of the appeals and grievance process under CMS, Medi-Cal, and PACE requirements
  

• Support authorization review, concurrent review, and denial management alongside nurse UM specialists
  

• Monitor for over- and under-utilization; spot patterns driving avoidable admissions and length-of-stay
  

• Provide oversight of HCC/ICD-10 diagnosis coding and RAF accuracy
  

• Develop medical policy and drive evidence-based clinical guideline adoption
  

• Partner with the CMO, Behavioral Health Director, Health Plan Director, and interdisciplinary teams
  

• Chair or sit on committees including credentialing and P&T
  

• Document to PACE, NCQA, and CMS standards and support audit readiness
  

What you'll need

Must have

• Active, unrestricted California MD or DO license
  

• Active DEA registration
  

• Current BLS
  

• Board certified or board eligible in a primary care specialty
  

• 5+ years of clinical practice in Internal Medicine, Geriatrics, and/or Family Medicine
  

• 3+ years in utilization/resource management or medical leadership within managed care, a health plan, or a value-based care setting
  

• Working command of Medicare and Medicaid/Medi-Cal regulations and CMS coverage criteria
  

• Experience applying evidence-based UM guidelines (InterQual preferred; MCG acceptable)
  

Nice to have

• PACE clinical or PACE utilization management experience
  

• Advanced degree — MPH, MHA, MBA, or MS
  

• ACLS
  

• Epic and QuickCap familiarity