Medical Director, Utilization Review
$260,000–$280,000 year
On-siteAustin, Texas, United States
Job Summary
Conduct comprehensive medical necessity reviews, including prospective, concurrent, and retrospective assessments, applying clinical expertise and evidence-based guidelines. Perform thorough prior authorization reviews ensuring alignment with clinical criteria, regulatory requirements, and contractual agreements. Lead effective peer-to-peer discussions with requesting practitioners to provide clear clinical rationales, facilitate open dialogue, and seek alternative solutions. Issue medical necessity denials when warranted with comprehensive, well-documented rationales in compliance with all relevant regulations and appeal processes. Collaborate closely with internal teams to optimize utilization management processes and contribute to the development of medical policies and clinical guidelines. Maintain meticulous documentation of all review activities and stay abreast of current medical literature and regulatory changes.
Required Qualifications
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school
- Board Certification in a medical specialty
- Active and unrestricted Medical License in at least one US state, with the ability to obtain additional state licenses as needed
- Minimum of 5 years of clinical practice experience
- Minimum of 2-3 years of experience in utilization management, medical review, or prior authorizations within an insurance or managed care organization
- Demonstrated success in conducting peer-to-peer discussions with external practitioners, with excellent communication and interpersonal skills
- Profound understanding of medical necessity criteria, evidence-based medicine, and healthcare utilization management principles
- Strong analytical and critical thinking skills, with the ability to synthesize complex clinical information and make sound medical decisions
- Exceptional written and verbal communication skills, capable of explaining complex medical decisions clearly and empathetically
- Proficiency with electronic health records (EHR) systems and utilization management software
- Self-motivated, highly organized, and able to manage a high volume of cases effectively in a remote work environment
- A 'roll up your sleeves' attitude and a genuine excitement for contributing to a rapidly growing, innovative startup
- No travel required for this position
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