Position Title: Remote Medical Director, Utilization Management
Salary Range: $260,000 – $280,000 (plus generous benefits, including a pension plan)
Position Overview
The Medical Director will play a key role in ensuring effective healthcare utilization management (UM), working closely with the Plan’s Chief Medical Officer. This leadership position involves providing clinical oversight, policy guidance, and collaborative support to improve the quality and efficiency of healthcare services.
Key Responsibilities

• Oversee utilization management for inpatient and home care services, with possible extension to out-of-network care.
• Lead peer-to-peer consultations and educate both in-network and out-of-network providers on healthcare policies and medical management protocols.
• Support new technology assessments and clinical policy reviews, backed by evidence-based research.
• Review medical necessity cases and handle appeal processes.
• Supervise retrospective claim reviews to identify trends that can reduce costs and improve care outcomes.
• Analyze patterns of service use or equipment to detect fraud, waste, and abuse.
• Collaborate with case managers by conducting rounds as necessary.
• Serve on department committees, such as Credentials and Medical Policy.
• Perform additional tasks related to utilization management, appeals, and clinical policy as assigned by the Chief Medical Officer.

Minimum Qualifications
Education: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) from an accredited institution.
Experience:

• At least 3 years of clinical experience.
• At least 2 years of experience in a managed care setting, with a focus on utilization management.

Licensure/Certification:

• Valid and current medical license in the state of New York.
• Board eligible or certified.

This position can be fully remote.