Physician-led utilization management for Medicare Advantage members, with a focus on prior authorization, concurrent inpatient review, retrospective review, and first-level appeals. The role makes medical necessity determinations, conducts peer-to-peer discussions with treating providers, and documents clinical rationale for timely review decisions. It also supports policy development, quality oversight, provider education, and collaboration with nursing and UM leadership in a highly regulated health plan setting.
Key Responsibilities
- Conduct physician-level medical necessity reviews for prior authorization, concurrent, and retrospective cases escalated from RN reviewers.
- Render timely determinations using Medicare guidelines, evidence-based criteria, plan policy, and applicable regulatory turnaround requirements.
- Conduct peer-to-peer discussions with attending physicians and treating providers before adverse determinations.
- Review first-level appeals and participate in independent or specialty peer review and ALJ hearings as needed.
- Provide clinical guidance and mentorship to RN reviewers and intake staff for complex or ambiguous cases.
- Participate in calibration sessions and interrater reliability testing to promote consistent review decisions.
- Support UM policy, escalation pathways, capacity planning, audits, and accreditation readiness.
- Participate in committees and present data on clinical outcomes, denial trends, and overturn rates.
Required
- Graduate of an accredited medical school.
- Current, active, unrestricted MD or DO license.
- Board certification in a relevant specialty such as Internal Medicine, Family Medicine, or Emergency Medicine.
- At least 5 years of active clinical practice experience in a relevant specialty.
- At least 2-3 years of utilization management, case management, or managed care experience in a health plan setting.
- Working knowledge of medical necessity criteria and UM regulatory and accreditation frameworks, including MCG, NCQA, URAC, and CMS.
Preferred
- Prior experience as a Medical Director or Associate Medical Director in a health plan, IPA, TPA, or Medicare managed care organization.
- Additional board certification or subspecialty training relevant to the member population, such as hospital medicine, geriatrics, or behavioral health.
- Experience with appeals and grievances, external review processes, or state fair hearings.
- Familiarity with population health, value-based care arrangements, or risk-adjustment programs.
- Local to California.
Benefits & Perks
- Base salary range of $213,100 to $383,580 per year.
- Mostly remote work model with approximately monthly travel to headquarters for in-person meetings and training.
- Annual employee bonus program.
- Robust wellness program.
- Generous paid time off, including 11 paid holidays, a floating holiday, and a birthday holiday.
- 401(k) retirement savings plan with employer match and contribution.
- Tuition reimbursement.
- Employee recognition program.