Medical Director – Utilization Management (Remote)

Role: Medical Director – Utilization Management
Client: Highmark (through Preferred Vendor)
Location: Fully Remote (USA)
Employment Type: Contract-to-Hire
Compensation: $120–130/hour on C2C (All Inclusive)
Work Authorization: US Citizens Only

Important Hiring Requirement

All shortlisted candidates must complete the Glider Assessment – “Medical Director Assessment” as part of the screening and evaluation process.

Job Summary

We are seeking experienced and highly motivated Medical Directors to join a physician-led Utilization Management team supporting Highmark. This role is responsible for conducting clinical reviews of escalated cases, evaluating medical necessity using established medical policies and evidence-based guidelines, and collaborating with multidisciplinary teams to support quality patient care and regulatory compliance.

The ideal candidate will possess strong clinical expertise, managed care experience, exceptional decision-making skills, and the ability to manage high review volumes effectively in a fully remote environment.

Key Responsibilities

• Conduct electronic utilization reviews for escalated clinical cases using established medical policy criteria and evidence-based guidelines.
• Evaluate medical necessity and appropriateness of requested treatments, procedures, and services.
• Perform peer-to-peer discussions with treating providers as needed to support clinical determinations.
• Review appeals, grievances, reconsiderations, and other assigned case types.
• Prepare clear, concise, and compliant determination rationales for providers, members, and internal stakeholders.
• Ensure adherence to NCQA, URAC, CMS, Department of Health (DOH), and Department of Labor (DOL) standards and regulations.
• Collaborate with multidisciplinary care management and disease management teams to improve patient outcomes.
• Participate in clinical team huddles, case reviews, quality discussions, and grand rounds.
• Assist in the development and refinement of clinical protocols, review criteria, and utilization management guidelines.
• Serve as a physician subject matter expert (SME) on operational, clinical, and strategic initiatives.
• Maintain productivity expectations of approximately 55+ case reviews per 8-hour workday.

Required Qualifications

• MD or DO degree from an accredited medical institution.
• Minimum of 5 years of direct patient care experience in hospital, outpatient, or private practice settings.
• Board Certification in a specialty recognized by:
  • American Board of Medical Specialties (ABMS), or
  • American Osteopathic Association (AOA) Specialty Certifying Boards.
• Active, unrestricted medical license in at least one of the following states:
  • Pennsylvania (PA)
  • New York (NY)
  • West Virginia (WV)
• Strong clinical judgment, analytical thinking, and decision-making abilities.
• Experience working in case management and/or managed care environments.
• Excellent written and verbal communication skills.
• Strong computer proficiency and experience using clinical documentation systems.

Preferred Qualifications

• Prior experience in Medical Management within a Health Insurance Plan.
• Strong understanding of utilization management processes and managed care operations.
• MBA, MPH, or related advanced degree preferred.
• Experience using platforms such as Predictal and Beacon is highly preferred.
• Previous remote utilization review experience is a plus.

Additional Information

• Fully remote opportunity within the United States.
• Contract role with strong potential for permanent conversion based on performance and business needs.
• Current hiring demand includes:
  • 10–11 Medical Directors for Non-Behavioral Health
  • 1–2 Medical Directors for Behavioral Health
    (Part-time candidates will be considered for Behavioral Health openings.)

Why Join This Opportunity?

• Work with a leading healthcare organization in a physician-led environment.
• Flexible remote work arrangement.
• Opportunity to contribute to quality-driven healthcare decisions at scale.
• Competitive compensation with long-term conversion potential.
• Collaborative and mission-driven clinical team culture.