Medical Director – Utilization Management & Worker's Compensation

Headquarters - Remotefull time

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Remote

senior

H1B: no

Council Capital Medical Director leads Utilization Management and Worker's Compensation clinical oversight and peer-to-peer payer engagement. The role provides clinical guidance for medical necessity determinations and supports utilization strategy and risk mitigation.

Responsibilities

Serve as the primary physician resource for UM decision-making, escalations, and complex case reviews
Provide clinical oversight and guidance for medical necessity determinations
Support concurrent and retrospective review processes as needed
Conduct physician-to-physician reviews with payers to support authorization approvals and overturn denials
Partner with UM and Revenue Cycle teams to improve payer communication strategies
Identify payer-specific trends and opportunities to improve outcomes
Educate providers on documentation best practices tied to medical necessity and payer criteria
Support audit preparation and response from a clinical perspective
Partner with Case Management, UM leadership, Revenue Cycle, Compliance, and Operations
Provide insights and recommendations based on denial trends and utilization data
Participate in leadership discussions related to utilization strategy and risk mitigation

Qualification

MD or DO with an activeBoard Certified in a relevant specialtyExperience in outpatientClinical Judgment – Applies soundCommunication – Clear

Required

MD or DO with an active, unrestricted medical license
Board Certified in a relevant specialty
Prior experience in Utilization Management, Physician Advisory, Medical Review, or similar role
Strong understanding of medical necessity, payer criteria, and utilization standards
Ability to communicate effectively with both clinicians and non-clinical leaders

Preferred

Experience working with commercial payers and managed care organizations
Prior peer-to-peer review experience with documented success overturning denials
Experience in outpatient, post-acute, or multi-site healthcare services environments
Exposure to healthcare services organizations operating in growth or PE-backed environments
Core Competencies (Scorecard Competencies)
Clinical Judgment – Applies sound, defensible medical decision-making
Influence Without Authority – Drives alignment across providers and payers
Communication – Clear, concise, and persuasive physician-to-physician dialogue