Medical Director, Utilization Management

Job Description

Location: Orlando, FL (Hybrid)

We are seeking a Medical Director, Utilization Management to lead utilization management, coverage determinations, and clinical appeals for a national health plan, ensuring members receive the right care at the right time. This position is a full-time, direct hire opportunity based in the Orlando, FL area on a hybrid schedule. The role guides a utilization management team across prior authorization, concurrent review, and appeals, and serves as a clinical leader and educator for the department.

This role is well aligned for a physician who is passionate about population health and clinical appropriateness and enjoys combining clinical expertise with leadership. The ideal candidate brings sound clinical judgment, strong regulatory knowledge, and a collaborative approach to working with treating physicians, nursing teams, and plan leadership.

Responsibilities:

• Direct utilization management activities, including prior authorization, concurrent review, and discharge planning
• Render coverage determinations on complex cases using evidence based criteria
• Conduct peer to peer reviews with treating physicians on adverse determinations
• Lead clinical appeals and grievance reviews in accordance with regulatory requirements
• Partner with nursing and care management teams to support appropriate care decisions
• Develop and maintain utilization management policies, guidelines, and coverage criteria
• Ensure compliance with URAC and NCQA accreditation and utilization management standards
• Serve as a clinical educator and resource for the utilization management team
• Monitor utilization management performance metrics and report findings to leadership

Qualifications:

• MD or DO with an active, unrestricted medical license required; multi-state licensure a plus
• Board certification in a clinical specialty required, with Internal Medicine, Family Medicine, Emergency Medicine, or a specialty with UM relevance preferred
• Minimum of 3 years of managed care, utilization management, or medical director experience
• Experience in a health plan, managed care organization, or insurance environment strongly preferred
• Strong working knowledge of InterQual or MCG clinical criteria and URAC and NCQA utilization management standards
• Excellent clinical judgment, written communication, and leadership skills

Schedule:

• Full-time position
• Hybrid schedule based in the Orlando, FL area, with a combination of onsite and remote days
• Monday through Friday, standard business hours (Eastern Time)
• 40 hours per week

Salary Range: The salary range for this position is approximately $200,000 – $250,000 annually ($96.15 – $120.19 per hour), based on experience and qualifications.

Interview Process:

Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.