Medical Director, State Utilization Management (Remote)

Summary

We are seeking a talented individual for a Medical Director who provides clinical leadership and direction for projects and contracts in support of the Corporate Mission, Vision, and Values.  The Medical Director also has responsibilities for Quality of Care, Peer Review, Clinical Expertise, Program Management and Development, Physician Review Panels, Quality of Care Review, Outcome Measurement Programs, HIPAA Privacy Expertise, Utilization Review, HIPAA Compliance, and Quality Assurance.  

Your role in our mission

• Manages all aspects of Recovery Audit Program including audit review and appeal process, provider education and training, quality assurance, literature research, and hearing support. 
• Provides clinical perspective and input to product development. 
• Coordinates activities of employed physician reviewers, part time and contract physician reviewers, and assistant Medical Directors. 
• Provides clinical expertise and support to corporate clients. 
• Analyzes health care data for new market development, current operations, utilization management, fraud waste & abuse. 
• Represents the organization in client presentations and responses to audits. 
• Supports the organizations' government and commercial clients in formal and informal hearings. 
• Provides clinical expertise to project teams as requested. 
• Represents the organization at contract/customer meetings to advocate for clinically relevant and economically feasible project studies. 
• Presents results of projects to relevant audiences to demonstrate the organization's position as a leader in Payment Integrity. 
• Performs literature searches as indicated to determine appropriateness of review decisions, to determine experimental status, and to determine cosmetic versus medical necessity issues. 
• Interacts with reviewers to clarify clinical issues, administrative issues, and scientific issues as they apply to specific reviews. 
• Monitors quality of reviewers and reviews for timeliness, completeness, and process compliance, while assuring appropriate levels of productivity and efficiency.  
• Participates on quality improvement teams in support of Quality Assurance as assigned. 

What we're looking for

• A minimum of five (5) years of experience in utilization review. 
• Must hold an active license (MD or DO), in good-standing. May require additional state specific medical licensure if needed. 
• Graduate of an approved school of either Medicine or Osteopathy required. Completed accredited residency in United States (or equivalent) residency program. 
• Five (5) years of experience in active practice. 
• Proficiency in creating, querying, and analyzing reports. 
• Experience and proficiency with InterQual and Milliman Care Guidelines. 
• Medium skill set with computer and software usage. 
• Strong writing skills with the ability to convey data in a clear and actionable manner. 
• Demonstrated expertise and knowledge able to apply commercially available utilization guidelines such as InterQual or MCG

What you should expect in this role

• Remote position within the U.S.
• 10% travel

The deadline to submit applications for this posting is December 4, 2026.