Medical Director
$332,800–$353,600 year
RemoteUnited States
Job Summary
Conduct electronic review of escalated cases against medical policy criteria, including telephonic peer-to-peer discussions, to determine medical necessity and appropriateness. Complete initial determinations of cases, appeals, and grievances while composing clear rationales for members and providers adhering to NCQA, URAC, CMS, and other regulations. Ensure medical management processes align with community standards of care and participate in the CMDM multidisciplinary team for case advice and protocol development. Actively manage projects requiring physician subject matter expertise. This full-time remote role supports CAI's global services firm in delivering tailor-made solutions across public and commercial sectors.
Required Qualifications
- Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
- Awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
- Active medical state licensure preferred for PA, NY, or WV, but will consider other US states, if candidate agrees to get licensed in PA
- 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
- Strong skills in Critical Thinking, Case Management, Customer Service, Oral & Written Communication, Collaboration, Listening, Telephone Skills, General Computer Skills, Clinical Software, and Managed Care
Desired Qualifications
- Master's Degree in Business Administration/Management or Public Health
- 1 year in Medical Management in a Health Insurance Plan
- strong knowledge of managed care industry
- Experience with MCG or InterQual
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