Job Description

Medical Director (Utilization Management)

Position Overview

The Medical Director plays a key role in ensuring coverage and payment determinations are clinically appropriate, compliant, and aligned with plan benefits and contractual agreements with participating provider networks. This position requires sound clinical judgment, collaborative leadership, and a strong understanding of healthcare delivery, population health, and payer operations.

Key Responsibilities

• Provide physician leadership and clinical guidance to Utilization Management and Care Management functions
• Render coverage and payment determinations in accordance with health plan benefits, medical policies, and provider contracts
• Apply evidence-based clinical guidelines and best practices to support consistent, high-quality decision-making
• Exercise informed medical judgment grounded in clinical medicine, patient safety, quality management, and population health principles
• Collaborate effectively with clinical teams, operational leaders, senior management, and external partners
• Promote efficient, cost-effective care delivery across all lines of business
• Support organizational initiatives related to quality improvement, compliance, and healthcare outcomes

Required Qualifications & Experience

• Medical Doctor (MD) or Doctor of Osteopathy (DO) from an accredited medical or osteopathic medical school recognized by AAMC, AOA, or WHO
• Unrestricted and active Pennsylvania medical or osteopathic license
• Current board certification through ABMS or AOBMS (Family Medicine or Internal Medicine preferred)
• Ability to successfully complete organizational credentialing requirements
• Strong knowledge of Utilization Management, healthcare delivery systems, and payer-based medical decision-making

Work Location

• Fully Remote: This position is designated as fully remote
• Work must be performed within the Tri-State Area (Pennsylvania, New Jersey, or Delaware)

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