Utilization Management, Medical Director

The Utilization Management, Medical Director is a key physician responsible for advancing clinical excellence, quality outcomes, utilization management, and provider engagement across the network. This role provides clinical oversight, supports evidence-based care delivery, and partners with providers, care management teams, and operational leaders to improve healthcare quality, patient outcomes, and effective stewardship of healthcare resources. The Medical Director helps ensure compliance with regulatory requirements, supports utilization and population health initiatives, and contributes to strategic growth through provider recruitment, retention, and network development.

Responsibilities

Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services; Develop and implement clinical protocols, guidelines, and standards; Monitor and evaluate clinical performance metrics and outcomes; Lead quality improvement initiatives to enhance patient care and safety; Oversee the implementation of evidence-based practices and clinical pathways; Conduct regular reviews of clinical data to identify areas for improvement; Partner with Quality, Care Management, and Population Health teams to improve HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics; Support identification and management of high-risk, high-cost, and high-opportunity patient populations; Foster strong relationships with network physicians and healthcare providers; Collaborate with providers to address clinical issues, improve care coordination, and promote best practices; Facilitate educational sessions and training programs for providers; Provide physician leadership for utilization management activities; Collaborate with care management, case management, and network providers; Participate in prospective, concurrent, and retrospective utilization review activities; Serve as a clinical resource for complex utilization, authorization, and care management cases; Support development, implementation, and refinement of utilization management policies, procedures, clinical criteria, and authorization guidelines; Analyze utilization trends, referral patterns, and opportunities for improved care coordination; Participate in appeals and peer-to-peer discussions with health plans and providers; Participate in and/or chair Utilization Management Committee meetings; Present utilization trends, performance metrics, and improvement opportunities to clinical and operational leadership; Ensure compliance with all regulatory requirements and industry standards; Manage audits and accreditation processes; Contribute to the development and execution of the IPA's strategic plan; Identify opportunities for growth and expansion of services; Participate in network expansion efforts; Participate in provider recruitment, interviews, onboarding, and orientation; Serve as AMG Friendly Physician for Southern California Region

Requirements

MD or DO degree from an accredited medical school; Active and unrestricted medical license; Minimum of 5 years of clinical experience, with at least 3 years in a leadership role; Board certification in a medical specialty; Strong understanding of quality improvement methodologies and healthcare regulations; Excellent communication, leadership, and interpersonal skills; Ability to analyze complex clinical data and develop actionable insights; Strong knowledge of utilization management, care management, population health, and value-based care principles; Ability to conduct medical necessity reviews and evaluate clinical appropriateness using evidence-based guidelines; Experience managing provider appeals, authorization reviews, and payer interactions; Understanding of HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics; Demonstrated ability to influence physician behavior through education, collaboration, and data-driven performance improvement

Nice to have

Experience in an IPA, health plan, ACO, delegated medical group, managed care, or value-based care environment; Experience with utilization management, medical necessity review, provider appeals, care management, population health, and quality improvement programs; Prior experience serving as a Medical Director, Associate Medical Director, or Physician Advisor supporting utilization management, care management, population health, or quality programs; Experience working with delegated managed care arrangements, health plan partners, and utilization management committees

Benefits

Excellent medical, vision, and dental coverage; 401k savings plan with a company match; Flexible time off; 9 Paid Holidays