Medical Director Utilization Management

Veterans Sourcing Group

Pittsburgh, PA(remote)

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JOB DETAILS

SKILLS

Business Administration, Case Management, Clinical Information Systems, Clinical Outcomes, Communication Skills, Computer Systems, Content Management Systems (CMS), Cross-Functional, Customer Escalations, Customer/Client Research, Disease Prevention and Control, Health Insurance, Hospital, Maintain Compliance, Managed Care, National Committee for Quality Assurance (NCQA), Onboarding, Operations Management, Osteopathy, Outpatient Care, Patient Care, Patient Care Authorizations, Policy Development, Presentation/Verbal Skills, Public Health, Regulations, Regulatory Compliance, Risk, Team Player, United States Citizen, Utilization Management, Utilization Review Accreditation Commission (URAC), Writing Skills

LOCATION

Pittsburgh, PA

POSTED

28 days ago

JOB DESCRIPTION

Medical Director Utilization Management (Payer Side Experience Required)- (Remote)
Duration: 30 Weeks with possible extension
Location: Pittsburgh, PA
Schedule: Monday Friday | 9:00 AM 5:00 PM EST Core Hours
Hours: 40 Hours/Week
Employment Type: Contract with Possibility of Full-Time Conversion
Work Authorization: Must be a US Citizen

Position Overview
This role supports Utilization Management activities within a health insurance/payer environment and is responsible for conducting medical necessity reviews, appeals, and escalated case evaluations using established medical policy criteria. The Medical Director will collaborate with multidisciplinary teams and provide physician expertise on complex and high-risk cases while ensuring compliance with all applicable regulatory standards.
The ideal candidate will have strong payer-side Utilization Management experience within a health insurance plan environment. Candidates whose experience is limited to hospital-side UM only may not be considered.

Responsibilities

Conduct electronic review of escalated cases against medical policy criteria to determine medical necessity and appropriateness of care.
Perform initial determinations, appeals, grievances, and additional assigned utilization reviews.
Participate in telephonic peer-to-peer discussions with providers as required.
Prepare clear and concise clinical rationales for provider and member determinations.
Ensure compliance with NCQA, URAC, CMS, DOH, DOL, and other regulatory standards.
Participate as physician member of multidisciplinary care and disease management teams.
Attend huddles, grand rounds, and provide physician expertise on high-risk or complex cases.
Assist with protocol and guideline development to support review consistency.
Participate in projects requiring physician subject matter expertise.
Support initiatives focused on improving member care and clinical outcomes.

Required Qualifications

Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
Minimum 5 years of direct patient care experience (hospital, outpatient, or private practice)
Board Certification in a specialty recognized by ABMS or AOA Specialty Certifying Boards
Active unrestricted medical license in PA, NY, or WV
Strong payer-side Utilization Management experience within a Health Insurance Plan
Experience reviewing medical necessity determinations, appeals, and grievances
Strong understanding of managed care and medical management processes
Excellent oral and written communication skills
Strong critical thinking and collaboration skills
Comfortable conducting provider peer-to-peer reviews
Proficiency with clinical software and general computer systems

Preferred Qualifications

MBA or Master's Degree in Public Health
Experience using MCG or InterQual guidelines
Prior experience with Predictal and Beacon systems
Managed care and payer-side case management experience

Additional Details

Fully Remote opportunity
Must complete Medical Director Assessment
Expected productivity: 55+ cases per 8-hour day
Systems used: Predictal and Beacon
Beeline used for timesheets and onboarding
Flexible scheduling after training completion

Candidate Categorization Requirement
Please categorize candidates in the submit form as one of the following:

Non Behavioral Health (Physical Health)
- Team requires approximately 10 11 hires
Behavioral Health
- Team requires approximately 1 2 hires
- Open to part-time candidates

Important Client Feedback
The manager has indicated that many previously interviewed candidates lacked sufficient payer-side Utilization Management experience. Candidates with only hospital-side UM experience are generally not aligned with the team's needs. Preference will be given to candidates with direct health insurance plan / payer-side UM experience involving medical necessity reviews, appeals, grievances, and managed care operations.

Medical Director Utilization Management

Veterans Sourcing Group

Pittsburgh, PA(remote)

About the Company

Veterans Sourcing Group

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