Lead Medical Director, Utilization Management

Accountabilities:: Complete assigned prior authorization, concurrent, retrospective, and other utilization management reviews, applying sound clinical judgment and meeting established turnaround expectations. Ensure medical necessity decisions are consistent with applicable evidence-based criteria, coverage policies, and clinical standards. Lead and manage a team of Utilization Management Medical Directors, supporting performance, clinical consistency, and effective decision-making. Review complex and escalated cases, seeking specialty consultation when appropriate. Develop, review, and maintain clinical policies, pharmacy policies, medical necessity criteria, and utilization management procedures in collaboration with clinical experts and operational teams. Monitor emerging clinical evidence and recommend policy updates to maintain current, appropriate, and consistent review standards. Chair the Utilization Management Committee by preparing agendas, presenting policy recommendations and utilization trends, documenting decisions, and ensuring follow-through on committee actions. Serve on the Credentialing Committee, providing physician expertise on provider qualifications, credentialing matters, and clinical concerns. Contribute to the Quality Committee by identifying trends in care quality, access, and outcomes and recommending improvement opportunities. Participate in physician peer-to-peer discussions, appeals, and provider education, communicating clinical decisions clearly and respectfully. Analyze audit findings, case reviews, appeals, complaints, and utilization management performance data to identify variation and improve policies, clinical practices, and workflows. Partner with care management, quality, compliance, network, pharmacy, and operations teams to address issues that span clinical programs. Support regulatory and accreditation readiness through appropriate clinical documentation, committee records, and corrective actions within the role's scope. Advise organizational leaders on utilization management strategy, clinical risks, and opportunities to improve member and provider experiences. Requirements: MD or DO degree. Active, unrestricted medical license. Board certification in a relevant clinical specialty. At least 5 years of clinical practice experience in utilization management or medical necessity review. At least 5 years of direct leadership experience managing a clinical team. Strong understanding of evidence-based clinical guidelines, medical necessity criteria, and healthcare coverage policies. Knowledge of applicable regulatory and accreditation requirements relevant to utilization management. Demonstrated clinical judgment and the ability to assess complex cases, interpret medical evidence, and make consistent, defensible decisions. Strong leadership and team management capabilities, including the ability to guide physician reviewers and support high-quality clinical performance. Excellent communication and conflict-resolution skills, particularly in peer-to-peer discussions, appeals, and interactions with providers. Ability to contribute effectively to multidisciplinary committees, communicate policy recommendations, and drive follow-through on decisions. Experience using case reviews, audits, and performance data to identify trends and support continuous improvement. Benefits: Base salary range: $320,000–$340,000 USD, with final compensation determined by factors such as experience, education, certifications, market data, and internal equity. Equity opportunities and a performance-based bonus program. 401(k) matching. Regular compensation reviews. Comprehensive medical, dental, and vision coverage. Flexible time-off policy. Remote-first work culture. No-Meeting Fridays and monthly company holidays. Mental health resources and initiatives supporting employee well-being. Paid parental leave for all new parents. Employee Stock Purchase Plan (ESPP) with discounted equity opportunities. Office setup expense reimbursement. Monthly cell phone and internet stipend. Learning programs, mentorship, professional development funding, and regular performance feedback. Collaborative, mission-driven environment focused on improving healthcare quality and member outcomes.