Utilization Management, Medical Director

Altais•Remote - CA, CA

6d•$186,000 - $223,200

About The Position

The Utilization Management, Medical Director is a key physician responsible for advancing clinical excellence, quality outcomes, utilization management, and provider engagement across the network. This role provides clinical oversight, supports evidence-based care delivery, and partners with providers, care management teams, and operational leaders to improve healthcare quality, patient outcomes, and effective stewardship of healthcare resources. The Medical Director helps ensure compliance with regulatory requirements, supports utilization and population health initiatives, and contributes to strategic growth through provider recruitment, retention, and network development. With a focus on aligning clinical, operational, and organizational priorities, this role serves as a trusted physician leader in advancing value-based care and high-performing provider networks.

Requirements

MD or DO degree from an accredited medical school
Active and unrestricted medical license
Minimum of 5 years of clinical experience, with at least 3 years in a leadership role
Board certification in a medical specialty
Strong understanding of quality improvement methodologies and healthcare regulations.
Excellent communication, leadership, and interpersonal skills.
Ability to analyze complex clinical data and develop actionable insights.
Strong knowledge of utilization management, care management, population health, and value-based care principles.
Ability to conduct medical necessity reviews and evaluate clinical appropriateness using evidence-based guidelines.
Experience managing provider appeals, authorization reviews, and payer interactions.
Understanding of HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics.
Demonstrated ability to influence physician behavior through education, collaboration, and data-driven performance improvement.

Nice To Haves

Experience in an IPA, health plan, ACO, delegated medical group, managed care, or value-based care environment.
Experience with utilization management, medical necessity review, provider appeals, care management, population health, and quality improvement programs strongly preferred.
Prior experience serving as a Medical Director, Associate Medical Director, or Physician Advisor supporting utilization management, care management, population health, or quality programs.
Experience working with delegated managed care arrangements, health plan partners, and utilization management committees.

Responsibilities

Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services.
Develop and implement clinical protocols, guidelines, and standards.
Monitor and evaluate clinical performance metrics and outcomes.
Lead quality improvement initiatives to enhance patient care and safety.
Oversee the implementation of evidence-based practices and clinical pathways.
Conduct regular reviews of clinical data to identify areas for improvement.
Partner with Quality, Care Management, and Population Health teams to improve HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics.
Support identification and management of high-risk, high-cost, and high-opportunity patient populations through data-driven interventions.
Foster strong relationships with network physicians and healthcare providers.
Collaborate with providers to address clinical issues, improve care coordination, and promote best practices.
Facilitate educational sessions and training programs for providers.
Provide physician leadership for utilization management activities, ensuring appropriate, effective, and evidence-based use of healthcare resources.
Collaborate with care management, case management, and network providers to support high-quality, cost-effective patient care across the continuum.
Participate in prospective, concurrent, and retrospective utilization review activities, including review of medical necessity determinations, treatment plans, hospital admissions, and specialty referrals.
Serve as a clinical resource for complex utilization, authorization, and care management cases.
Support development, implementation, and ongoing refinement of utilization management policies, procedures, clinical criteria, and authorization guidelines.
Analyze utilization trends, referral patterns, inpatient and outpatient utilization data, and opportunities for improved care coordination and resource stewardship.
Partner with operational and clinical leaders to achieve utilization, quality, and population health performance goals.
Participate in appeals and peer-to-peer discussions with health plans and providers regarding medical necessity and coverage determinations when appropriate.
Provide clinical oversight and input related to high-risk patient management, transitions of care, and complex case reviews.
Support provider education regarding utilization management principles, evidence-based practice standards, and appropriate resource utilization.
Participate in and/or chair Utilization Management Committee meetings as assigned.
Present utilization trends, performance metrics, and improvement opportunities to clinical and operational leadership.
Provide clinical leadership in the development of UM strategies that improve outcomes while maintaining responsible stewardship of healthcare resources.
Collaborate with Quality, Population Health, and Care Management teams to align utilization management activities with organizational goals.
Ensure compliance with all regulatory requirements and industry standards.
Stay updated on changes in healthcare regulations and implement necessary adjustments.
Manage audits and accreditation processes.
Contribute to the development and execution of the IPA's strategic plan.
Identify opportunities for growth and expansion of services.
Collaborate with executive leadership to align clinical goals with organizational objectives.
Participate in network expansion efforts through presentations, outreach to strategic provider prospects.
Participate in recruitment outreach activities, employment fairs, residency program events, other events as identified/prioritized by President, SCAL Network.
Actively participate in all physician candidate interviews, once physician has passed through initial screening.
Develop and maintain relationship with physician candidates in final round of selection process, and throughout onboarding process if/when hired.
Participate in onboarding/orientation of new physicians after start date.
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