In this remote medical director role, the clinician reviews escalated utilization management cases to determine medical necessity and appropriateness, including initial determinations and appeals. The work centers on applying medical policy and current clinical standards, with telephonic peer-to-peer discussions as needed. The role also includes collaboration with a multidisciplinary team and participation in protocol, guideline, and project work.
Key Responsibilities
- Conduct electronic reviews of escalated cases against medical policy criteria.
- Perform initial determinations, appeals reviews, and grievance reviews as assigned.
- Participate in telephonic peer-to-peer discussions to support case review decisions.
- Write clear rationales for member and provider notifications while meeting compliance standards.
- Ensure medical management decisions align with community standards of care.
- Participate in multidisciplinary huddles and grand rounds to advise on cases requiring physician expertise.
- Contribute to protocol and guideline development to support consistent review processes.
- Manage projects or serve as a physician subject matter expert on project teams.
Required
- Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) degree.
- Board certification at least once in a specialty recognized by the ABMS or AOA Specialty Certifying Boards.
- Active medical state licensure for Pennsylvania, New York, or West Virginia.
- At least 5 years of clinical direct patient care experience in hospital, outpatient, or private practice settings.
Preferred
- Master’s degree in Business Administration/Management or Public Health.
- At least 1 year of medical management experience in a health insurance plan.
- Experience with MCG or InterQual.
- Strong knowledge of the managed care industry.
Benefits & Perks
- Remote work arrangement.
- Medical, dental, and vision insurance.
- 401(k) retirement account access.
- Paid sick leave and/or other paid time off, as provided by applicable law.
- Hourly pay range of $160 to $170.