Utilization Management Physician Medical Director

SCAN Health Plan • Los Angeles, CA

2d • Remote

About The Position

The Utilization Management (UM) Physician Medical Director provides physician-level clinical leadership and decision-making for the organization's prior authorization, concurrent review, and appeals programs. This role serves as the clinical authority for medical necessity determinations that cannot be approved by RN reviewers, conducts peer-to-peer discussions with treating providers, and partners with UM leadership to ensure the program delivers timely, clinically sound, and cost-effective determinations consistent with evidence-based guidelines, applicable regulatory requirements, and NCQA/URAC accreditation standards. The Medical Director also contributes to program strategy, policy development, quality oversight, and provider education. Ideally the selected candidate will be local to California.

Requirements

• Graduate of an accredited medical school
• Current, active, unrestricted medical license; willingness to obtain additional state licensure as required by the role.
• Board certification in good standing in a relevant specialty (e.g., Internal Medicine, Family Medicine, Emergency Medicine).
• Minimum of 5 years of active clinical practice experience.
• Minimum of 2–3 years of utilization management, case management, or managed care experience, including medical necessity review and peer-to-peer clinical discussions.
• Working knowledge of nationally recognized medical necessity criteria (e.g., MCG) and UM regulatory/accreditation frameworks (NCQA, URAC, CMS).
• Working knowledge of Medicare decisioning including use of National Coverage Determinations, Local Coverage Determinations, Medicare Benefits Policy Manual.
• Advanced analytical skills
• In-Depth understanding of the business
• Good problem-solving skills
• Good communication and interpersonal skills
• Sound, well-documented clinical judgment and the ability to apply evidence-based criteria consistently and defensibly.
• Strong verbal and written communication skills, including the ability to explain clinical rationale to providers, members, and non-clinical stakeholders.
• Comfort with a high-volume, deadline-driven review queue and regulatory turn around-time requirements.
• Collaborative leadership style; ability to mentor and calibrate a multidisciplinary review team (RNs, intake staff, other physicians).
• Proficiency with UM/clinical workflow platforms, electronic health records, and standard office/productivity software.
• Sound understanding of healthcare regulatory, compliance, and accreditation requirements applicable to UM programs.

Nice To Haves

• Prior experience as a Medical Director or Associate Medical Director within a health plan, IPA, TPA, or Medicare Managed Care Organization.
• Additional board certification or subspecialty training relevant to the plan's membership (e.g., hospital medicine, geriatrics, behavioral health).
• Experience with appeals and grievances, external review processes, and state fair hearing participation.
• Familiarity with population health, value-based care arrangements, or risk-adjustment programs.
• Curious about AI and its power to transform how we operate and serve our members.

Responsibilities

• Perform physician-level medical necessity review of prior authorization requests, concurrent (inpatient) reviews, and retrospective reviews referred by RN reviewers when clinical criteria are not clearly met.
• Render timely determinations consistent with Medicare guidelines, nationally recognized clinical criteria (MCG), evidence-based guidelines, plan policy, standard of care, and applicable state and federal turnaround-time requirements.
• Conduct peer-to-peer discussions with attending physicians and treating providers prior to issuing an adverse determination, and document clinical rationale clearly and defensibly.
• Serve as a physician reviewer for first-level appeals and, where required, refer cases to independent or specialty peer review, participate in ALJ Hearings as required.
• Maintain availability for urgent/expedited reviews within required turnaround windows.
• Partner with the UM Director/VP, nursing leadership, Medical Policy, and Grievance and Appeals Department to set clinical review policy, escalation pathways, and criteria adoption/customization.
• Provide clinical guidance and mentorship to RN reviewers and intake staff; serve as a point of escalation for complex or ambiguous cases.
• Participate in interrater reliability (IRR) testing and calibration sessions to ensure consistent application of clinical criteria across the review team.
• Support workforce and capacity planning by advising on case complexity trends, criteria changes, and clinical review time standards.
• Ensure UM decisions and documentation meet NCQA/URAC accreditation standards and applicable state/federal regulatory requirements (e.g., CMS, state DOI/Medicaid rules).
• Participate in the UM Committee, Quality Improvement Committee, and UM Data discussion venues; present clinical outcomes, denial trends, and overturn-rate data.
• Support internal and external audits, regulatory examinations, and delegation oversight reviews related to UM.
• Identify and help remediate patterns of inappropriate utilization, quality-of-care concerns, or potential fraud, waste, and abuse, escalating as appropriate.
• Communicate professionally and collaboratively with network and non-network providers regarding review determinations and clinical criteria.
• Support provider education on UM policies, submission requirements, and clinical documentation expectations to reduce avoidable denials.
• Represent the UM program in provider disputes, credentialing/quality committees, and external clinical forums as needed.
• Actively support the achievement of SCAN’s Vision and Goals.
• Other duties as assigned.

Benefits

• Base salary range: $213,100 to $308,301 per year
• Annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match and contribution
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Ph.D. or professional degree