Medical Director

Job Description Summary

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The Utilization Management (UM) Medical Director provides clinical leadership for the UM program, ensuring members receive appropriate, high-quality care. You will oversee review guidelines, collaborate with internal teams and external partners, and drive compliance with regulatory and accreditation standards.

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How will you make an impact & Requirements

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With nearly 30 years of experience in providing advanced primary care, CareMore APC delivers exceptional patient experiences. Compassionate clinicians take the time to understand each patient’s unique health needs while also removing barriers to access. Patients trust us to receive the right personalized care where and when they need it – in our care centers, at home or virtually – to improve their health outcomes and quality of life.

Key Responsibilities

• Lead the development, implementation, and periodic review of UM policies and clinical criteria
• Provide physician oversight for concurrent and retrospective review activities
• Approve and interpret clinical guidelines, pathways, and criteria for admission, continued stay, and discharge
• Serve as the primary clinical liaison with payers, providers, and regulatory bodies
• Mentor and educate UM nurses, physician reviewers, and other staff on best practices
• Analyze utilization data and quality metrics to identify trends and areas for improvement
• Participate in appeals and peer-to-peer discussions to resolve clinical disputes
• Maintain compliance with NCQA, URAC, CMS, state regulations, and organizational standards

Qualifications

• Medical degree (MD or DO) from an accredited institution
• Active, unrestricted medical license in [State/Region]
• Board certification in an acute-care specialty (e.g., Internal Medicine, Family Medicine, Pediatrics)
• Minimum of 5 years clinical practice experience, with 2+ years in utilization management or managed care

Compensation: $263,488K - $329,360K & bonus eligible

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