Medical Director - Utilization Management

Description

• Put Patients First  
• Empower Entrepreneurial Provider and Care Teams  
• Operate with Integrity & Excellence  
• Be Innovative  
• Work As One Team 

What You'll Do

• Review and issue timely determinations for prior authorization requests, ensuring medical necessity, regulatory compliance, and alignment with evidence-based clinical guidelines.
• Collaborate with care management and operational teams to streamline and enhance prior authorization workflows for efficiency and provider satisfaction.
• Provide clinical leadership in the development, implementation, and regular updating of authorization criteria and policies based on the latest medical standards.
• Promote transparency by clearly documenting and communicating authorization decisions to providers and members, including rationale and guidance for alternative treatment options when applicable.

• Provide oversight for the daily activities of the UM program, ensuring services are delivered appropriately and in accordance with clinical best practices.
• Analyze utilization data to identify trends, high-cost drivers, and opportunities for care optimization and cost containment.
• Participate in the clinical review of complex or high-cost cases, offering recommendations rooted in medical necessity and member-centered care.
• Collaborate with interdisciplinary clinical teams to ensure the appropriate use of healthcare resources without compromising quality.

• Ensure all UM activities meet applicable federal, state, and accreditation standards (e.g., CMS, NCQA).
• Lead and contribute to quality improvement initiatives focused on enhancing the effectiveness, accuracy, and consistency of the prior authorization and UM processes.
• Conduct audits and peer reviews to validate adherence to guidelines and evaluate the quality of medical decision-making.

• Serve as the primary clinical contact for complex medical necessity determinations and escalated provider appeals.
• Build strong working relationships with providers by offering education and clarity around the prior authorization process and criteria.
• Support member care continuity by suggesting medically appropriate alternatives when requested services are denied.

• Ensure full compliance with all applicable UM regulatory and accreditation standards, including NCQA and CMS requirements.
• Maintain up-to-date knowledge of evolving healthcare laws, policies, and industry standards affecting prior authorization and UM processes.
• Lead internal efforts to prepare for and maintain UM-related accreditation, including audits, documentation, and process improvement.

• Monitor and analyze prior authorization and UM metrics (e.g., denial rates, turnaround times, appeal volumes) to identify performance gaps and track progress.
• Use data-driven insights to inform strategic decisions, improve process efficiency, and support cost management goals.
• Provide regular updates and reporting to senior leadership on program performance, cost impact, compliance status, and quality indicators.
• Other duties across all areas as assigned.

Qualifications

• Medical Degree (MD or DO) from an accredited institution; active and unrestricted medical license in CA.
• Board certification (preferred) in a relevant specialty (e.g., Internal Medicine, Family Medicine, or equivalent).
• At least 5 years of clinical practice experience.
• At least 3 years of experience in utilization management or medical management within a health plan, IPA/MSO, or risk-bearing organization.
• Deep knowledge of managed care, value-based care, capitation, and CMS/Medi-Cal guidelines.
• Proficient in applying MCG, InterQual, or equivalent criteria.
• Strong understanding of state and federal regulations (e.g., CMS, DMHC, NCQA).
• Excellent communication skills, including the ability to engage providers in meaningful, respectful clinical dialogue.
• Highly collaborative mindset with a commitment to improving healthcare equity, quality, and cost-effectiveness.

Environmental Job Requirements and Working Conditions

• This position is fully remote, with some travel to SoCal required as needed. Candidates must have a CA medical license. 
• The national target base salary range for this role is: $275,000 - $325,000. Actual compensation will be determined based on geographic location (current or future), experience, or other job-related factors.