Medical Director, Utilization Review

Job Summary

Seeking a dedicated Medical Director, Utilization Review, this full-time remote position will manage utilization reviews, prior authorizations, and medical necessity determinations while fostering relationships with practitioners in a dynamic startup environment.

Key Responsibilities:

• Perform comprehensive medical necessity reviews for various healthcare services, applying clinical expertise and evidence-based guidelines
• Conduct prior authorization reviews to ensure compliance with clinical criteria and regulatory requirements
• Lead peer-to-peer discussions with practitioners, providing clear rationales for medical determinations and exploring alternative solutions

Required Qualifications:

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school
• Board Certification in a medical specialty
• Active and unrestricted Medical License in at least one US state
• Minimum of 5 years of clinical practice experience and 2-3 years in utilization management or medical review
• Strong understanding of medical necessity criteria and healthcare utilization management principles