Medical Director - Utilization Management

Astrana Health, Inc.•Monterey Park, CA

2d•$275,000 - $325,000•Hybrid

About The Position

As Medical Director - Utilization (UM) at Astrana Health, you will provide clinical oversight and strategic leadership through our utilization review operations to ensure members receive high-quality, medically appropriate, and cost-effective care. This is a critical, cross-functional role that bridges clinical expertise with operational execution across value-based care, capitated models, and delegated risk structures. You’ll work closely with teams in Care Management, Quality Improvement, Pharmacy, Behavioral Health, and Compliance to drive aligned decision-making that supports both optimal patient outcomes and efficient healthcare resource use. In this role, you’ll apply evidence-based criteria to utilization decisions, mentor clinical review teams, and support compliance with all applicable regulatory and contractual obligations. This position is ideal for a clinically grounded physician who thrives in a data-informed, team-based environment and is passionate about transforming how care is delivered in a risk-bearing, population health-focused ecosystem. Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team

Requirements

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).
Minimum 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.

Nice To Haves

Board certification (preferred) in a relevant specialty (e.g., Internal Medicine, Family Medicine, or equivalent).

Responsibilities

Prior Authorization Management
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.
Utilization Management
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.
Quality Assurance and Improvement
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.
Provider and Member Communication
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.
Regulatory Compliance and Accreditation
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.
Data Analysis and Reporting
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.