Job Description
Job DescriptionJob ProfileJob Title: Medical Director Location: Remote.Hire Type: ContingentPay Range: $OpenWork Model:RemoteWork Shift: 8 hours per day 40 hrs. per week Recruiter Contact:Sean Craft I sean@marykraft.com I 443-345-3305Nature & Scope:Positional OverviewWe are seeking a Medical Director – Utilization Management Physician to join our growing Utilization Management (UM) team. This role is ideal for a board-certified internal medicine or family medicine physician with strong experience in hospitalist medicine and a passion for improving health care efficiency and quality outcomes.As a clinician-led organization, Optum empowers physicians to focus on what they do best—delivering high-quality, compassionate care—while supporting their professional growth and work-life balance. The Medical Director will play a pivotal role in evaluating medical necessities, guiding UM protocols, and ensuring compliance with CMS and health plan requirements.Role & Responsibility:Tasks That Will Lead to Your Success
- Conduct clinical reviews for medical necessity and appropriateness of services, with a focus on post-service and acute admissions.
- Assist in developing and maintaining UM protocols that align with CMS criteria, company standards, and accepted medical practices.
- Analyze utilization trends to detect over- or under-utilization and recommend corrective actions or process improvements.
- Contribute to the development of care management and medical management strategies and guidelines.
- Provide second-level review for escalated clinical cases as necessary.
- Stay current with CMS regulations and delegated health plan requirements related to UM.
- Ensure all reviews and decisions are well-documented and compliant with federal and state regulations.
- Support quality assurance by educating staff on current medical guidelines and evidence-based practices.
- Provide support and training to internal physicians and new hires on UM policies and review criteria.
- Maintain professional and responsive communication with peers, providers, and staff.
- Participate in medical team meetings, training sessions, and continuing education efforts.
- Promote a culture of collaboration, learning, and operational excellence within the UM team.
Skills & ExperienceQualifications That Will Help You Thrive
- Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), or M.B.B.S.
- Board Certification in Internal Medicine or Family Medicine
- Active, unrestricted medical license (any U.S. state)
- 5+ years of post-residency clinical experience
- Proficiency in Microsoft Office Suite (Word, Excel, Outlook)
- 2+ years of experience in utilization management or case review
- Experience in hospitalist or acute care settings
- Experience working in a managed care or health plan environment
- Bilingual in English and Spanish (highly preferred)