Medical Director, Utilization Management Job at L.A. Care Health Plan (Los Angeles)

Medical Director of Case Management and Utilization Review

The Medical Director of Case Management and Utilization Review leads the hospita...

Location

United States , Miramar

Salary:

Not provided

Memorial Healthcare System

Expiration Date

Until further notice

Requirements

Medical Doctor (Required)
Medical Doctor License (ME LICENSE) - State of Florida (FL)
Osteopathic Physician License (OS LICENSE) - State of Florida (FL)
Extensive experience in one or more branches of medicine or surgery
at least, five (5) post-training years of medical staff organization/administrative experience in a large acute care hospital
Graduate of a medical school approved by the Council on Medical Education of the American Medical Association
Excellent customer service and interpersonal skills
Able to effectively present information, both formal and informal
Strong written and verbal communications skills with all levels of internal and external customers
Strong analytical skills

Job Responsibility

Supports education and clinical documentation improvement
Leads Complex Care Management
Leads hospital initiatives to reduce complex patient length of stay
Makes decisions on referred individual patient cases regarding pre-admission authorization, medical necessity and services/setting, appropriateness of admission, and continuation stay
Provides peer review services for medical necessity of admission or continued stay
Supports the Senior Medical Director in Medical Staff Education
Assists physicians in improving the quality of their medical necessity documentation
Serves as liaison to insurance companies for prior authorizations and removes barriers to discharge
Supports case management by attending interdisciplinary rounds (IDR) and provides feedback and suggestions to physicians and CMs
Serves as liaison to case management, social workers, nursing staff, individual physicians, and the medical staff

Fulltime

Medical Director

Medical Director (Part-Time) Care Management California, United States Because...

Location

United States , California

Salary:

91.00 - 114.00 USD / Hour

Personify Health

Expiration Date

Until further notice

Requirements

MD or DO degree and 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment
Current and ongoing Board Certification in an approved ABMS Medical Specialty
A current and unrestricted license in the state of California and willing to obtain additional license(s), if needed. (Optional)
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
Minimum 5 years of Utilization Review or Hospital experience required
Minimum 3 years of compliance related experience preferred
Managed Care experience preferred in utilization review and case management
Basic computer literacy
The ability to work on multiple screens, and proficient typing skills
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook

Job Responsibility

The Medical Director relies on their medical background to review claims for medical necessity for prior authorization, continued stay review and post service
The Medical Director can read, interpret, and apply medical policy, guidelines, and research to utilization review
The Medical Director has authority for issuing adverse determinations while performing medical necessity evaluation
Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances, these may require conflict resolution skills
Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope
Keep the team informed of clinical updates through educational opportunities by developing educational materials for staff
Work with the VP of Care management to establish work procedures and processes that support company and departmental standards, procedures, and strategic directives
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services (such as inpatient rehabilitation)
Knowledge of the managed care industry as it relates to commercial business

What we offer

Part-time schedule designed around your availability and life priorities
Access to learning and development opportunities alongside full-time colleagues
Mentorship and skill-building that translates to career advancement
Competitive hourly compensation that values your expertise
Technology and equipment support to set you up for success

Parttime

Substance Use Medical Director

The Division of Behavioral Health and Recovery is seeking to hire an experienced...

Location

United States , Chicago

Salary:

25092.00 - 27092.00 USD / Month ▼

Illinois Department of Public Health (IDPH)

Expiration Date

June 29, 2026

Requirements

Valid Illinois license to practice medicine
American Board of Specialties certification or its equivalent in Family Practice, preferably in the subspecialty of Addiction Medicine
Three (3) years of substantive medical administrative experience directing, planning and evaluating a medical/clinical or medical program

Job Responsibility

Serves as Substance Use Medical Director and medical advisor to Division of Behavioral Health and Recovery (DBHR) for utilization management, current trends in medication interventions, new psycho-social therapies, disease management, outcomes monitoring and research practice related to substance use disorders
Serves as medical advisor for DBHR for the integration of behavioral and physical health care within the Division and coordinates efforts with internal and external stakeholders
Provide medical director leadership in the development of best practice in addiction treatment services
Provides expertise and leadership for integrated behavioral healthcare systems and clinical programming for co-occurring disorders in adult and adolescent populations by supporting the delivery of developmentally appropriate substance use disorder services to adolescents
Serves as medical consultant to DBHR to provide clarification, review and determination for policies, procedures, grants, contracts, treatment and intervention services, legislation, administrative rules, and other relevant areas
Performs other duties as required or assigned which are reasonably within the scope of the duties enumerated above

What we offer

A Pension Program
Competitive Group Insurance Benefits including Health, Life, Dental and Vision Insurance
3 Paid Personal Business Days annually
12 Paid Sick Days annually (Sick days carry over from year to year)
10-25 Days of Paid Vacation time annually - (10 days in year one of employment)
Personal, Sick, & Vacation rates modified for 12-hour & part-time work schedules (as applicable)
13 Paid Holidays annually, 14 on even numbered years
Flexible Work Schedules (when available dependent upon position)
12 Weeks Paid Parental Leave
Deferred Compensation Program - A supplemental retirement plan

Parttime

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Utilization Management Representative

We are looking for a dedicated Utilization Management Representative to join our...

Location

United States , Pearland

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

1–3 years of healthcare experience (utilization management, insurance operations, or medical office preferred)
Experience handling high call volumes in a professional environment
Strong data entry and documentation accuracy
Ability to multitask in a fast-paced setting
Effective communication skills with providers, members, and internal teams
Basic understanding of authorization processes in healthcare or insurance
Experience with EMR/EHR or case management systems
Strong organizational and time management skills

Job Responsibility

Handle inbound calls from providers, members, and facilities regarding authorization requests, status updates, and coverage questions
Review and process authorization requests received via phone, fax, and electronic systems
Create and document authorization cases accurately within utilization management systems or EHR platforms
Route cases requiring medical necessity review to clinical staff (RNs, LVNs, Medical Directors)
Communicate authorization determinations to providers and members in compliance with regulatory requirements
Maintain accurate, timely documentation to support compliance and operational standards
Collaborate with internal teams to ensure efficient case processing and resolution

What we offer

medical
vision
dental
life and disability insurance
401(k) plan

Appeals Medical Director - Cardiology

The Appeals Medical Director for Cardiology is responsible for the appeal review...

Location

United States of America

Salary:

247840.00 - 446112.00 USD / Year

Elevance Health

Expiration Date

June 26, 2026

Requirements

Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)
Must possess an active unrestricted medical license to practice medicine or a health profession
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US
Minimum of 10 years of clinical experience
or any combination of education and experience, which would provide an equivalent background
For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required
Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.

Job Responsibility

Appeal Reviews
Supports clinicians to ensure timely and consistent responses to members and providers
Provides guidance for clinical operational aspects of a program
May conduct peer-to-peer clinical case reviews with attending physicians or other ordering providers to discuss review determinations
Serves as a resource and consultant for other areas of the company
May be required to represent the company to external entities and/or serve on internal and/or external committees
May chair company committees
Interprets medical policies and clinical guidelines
May develop and propose new medical policies based on changes in healthcare
Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes

What we offer

comprehensive benefits package
incentive and recognition programs
equity stock purchase
401k contribution
merit increases
paid holidays
Paid Time Off
incentive bonus programs
medical
dental

Fulltime

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Appeals Medical Director - Urology

The Appeals Medical Director for Urology is responsible for the appeal reviews f...

Location

United States , Woodland Hills

Salary:

247840.00 - 446112.00 USD / Year

Elevance Health

Expiration Date

June 26, 2026

Requirements

Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)
Must possess an active unrestricted medical license to practice medicine or a health profession
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US
Minimum of 10 years of clinical experience
or any combination of education and experience, which would provide an equivalent background
For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required
Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency

Job Responsibility

Appeal Reviews
Supports clinicians to ensure timely and consistent responses to members and providers
Provides guidance for clinical operational aspects of a program
May conduct peer-to-peer clinical case reviews with attending physicians or other ordering providers to discuss review determinations
Serves as a resource and consultant for other areas of the company
May be required to represent the company to external entities and/or serve on internal and/or external committees
May chair company committees
Interprets medical policies and clinical guidelines
May develop and propose new medical policies based on changes in healthcare
Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes

What we offer

comprehensive benefits package
incentive and recognition programs
equity stock purchase
401k contribution
merit increases
paid holidays
Paid Time Off
incentive bonus programs
medical, dental, vision
short and long term disability benefits

Fulltime

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Medical Director - Behavioral Health

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Work at Home

Salary:

174070.00 - 374920.00 USD / Year

CVS Health

Expiration Date

June 30, 2026

Requirements

Board Certification in Psychiatry
Minimum 5 years of clinical practice experience in the health care delivery field as a psychiatrist
Hold current California medical license or be able to obtain California, Texas and Arizona license
Active and current state medical license without encumbrances
MD or DO

Job Responsibility

Provide comprehensive behavioral health care management to facilitate delivery of appropriate quality care and improve program/operational efficiency involving clinical issues
Provide leadership and day-to-day physician oversight for utilization management team, including the management of high-risk cases and medical necessity decisions
Participate in the development, implementation, and evaluation of clinical/medical programs
Provide psychiatric leadership to an interdisciplinary utilization management team, including medical/clinical oversight, consultation and training
Provide day-to-day physician oversight including management of high-risk cases throughout treatment/levels of care and medical necessity decisions
Assist with the development, implementation, monitoring and evaluation of the utilization management program and action plan, ensuring quality and appropriateness of care
Assist with the development, implementation and interpretation of medical policy including medical necessity criteria, clinical practice guidelines and new technology assessments
Confer with behavioral health practitioners regarding the care of patients with severe, complex and/or treatment resistant illnesses
Identify and address quality of care concerns with providers involved in a member's care
Participate in the appeals process, including the investigation of adverse events and quality of care concerns

What we offer

Medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs
other resources

Fulltime

Medical Director, Clinical Policy

The Medical Director, Clinical Policy provides clinical leadership and strategic...

Location

United States , Los Angeles

Salary:

206311.00 - 350729.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Doctor of Medicine (M.D.)
At least 8 years of experience in managed care, clinical policy development, or utilization management leadership
Extensive post-medical degree experience in clinical practice
Significant experience in a clinical development, medical affairs, or management role within the biotech, pharmaceutical, or healthcare industry
Proven experience in a physician leadership role, including managing teams
Board Certified, preferably in a primary or medical specialty - Active, current and unrestricted California license
Current clinical license to practice or an administrative license to review Utilization Management (UM) cases

Job Responsibility

Provide executive clinical leadership in the development, review, approval, and ongoing oversight of clinical policies and coverage criteria
Ensure all clinical policies comply with applicable federal, state, and accreditation requirements
Monitor emerging medical technologies, procedures, evidence-based practices, and external benchmarks
Provide strategic oversight of benefit design and clinical architecture
Validate codes, rules, and clinical logic are appropriately aligned and consistently applied
Oversee authorization matrix strategy and governance
Provide clinical direction for prior authorization requirements
Oversee the Clinical Criteria Hierarchy
Guide the strategic development of pre-payment review approaches
Oversee service-level utilization tracking and analysis

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

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Medical Director, Utilization Management

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