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Medical Director Utilization Management Jobs (NOW HIRING)

Wellpath

Director Utilization Mgmt

Lemoyne, PA · On-site

Overview The Medical Director of Utilization Management leads and oversees utilization review, case management, quality improvement, and related policy and practice initiatives within their assigned ...

Wellpath

Director Utilization Mgmt

Lemoyne, PA · On-site

$199K - $249K/yr

How you make a difference The Medical Director of Utilization Management leads and oversees utilization review, case management, quality improvement, and related policy and practice initiatives ...

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Medical Director Utilization Management information

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$13K

$232.4K

$357K

How much do medical director utilization management jobs pay per year?

As of Jun 12, 2026, the average yearly pay for medical director utilization management in the United States is $232,369.00, according to ZipRecruiter salary data. Most workers in this role earn between $198,000.00 and $284,500.00 per year, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a Medical Director Utilization Management, and why are they important?

To thrive as a Medical Director Utilization Management, you need a medical degree (MD or DO), board certification, and extensive clinical experience, often in internal medicine or a related specialty. Familiarity with utilization review processes, case management software, and regulatory frameworks such as CMS guidelines is essential. Strong leadership, analytical thinking, and effective communication skills are crucial for guiding teams and collaborating with diverse stakeholders. These competencies ensure appropriate resource utilization, regulatory compliance, and high-quality patient care within healthcare organizations.

How does a Medical Director in Utilization Management typically collaborate with clinical teams and insurance providers?

A Medical Director in Utilization Management frequently works at the intersection of healthcare providers, clinical teams, and insurance companies. Their role involves reviewing clinical cases, making coverage determinations, and consulting with physicians to ensure that medical treatments are both necessary and cost-effective. Collaboration often includes participating in interdisciplinary meetings, providing guidance on complex cases, and communicating policy updates or clinical guidelines. This ensures that patient care decisions align with best practices, regulatory requirements, and payer policies.

What is a Medical Director Utilization Management?

A Medical Director of Utilization Management is a physician who oversees and ensures the appropriate use of medical resources within a healthcare organization or insurance company. Their responsibilities include reviewing clinical cases, developing utilization review policies, and working with healthcare providers to ensure that treatment plans are medically necessary and cost-effective. They play a key role in balancing patient care quality with regulatory and financial considerations, helping to improve healthcare outcomes and system efficiency.

What is the difference between Medical Director Utilization Management vs Medical Director Case Management?

AspectMedical Director Utilization ManagementMedical Director Case Management
CredentialsMedical degree, medical license, possibly board certificationMedical degree, medical license, possibly board certification
Work EnvironmentUtilization review departments, insurance companies, healthcare organizationsCase management teams, hospitals, healthcare providers
Employer & IndustryInsurance companies, managed care organizationsHospitals, healthcare systems, community health agencies
Primary FocusReviewing medical necessity and approving servicesCoordinating patient care and discharge planning

Both roles require medical credentials and involve improving patient care, but Medical Director Utilization Management primarily focuses on reviewing and approving healthcare services for insurance purposes, while Medical Director Case Management emphasizes coordinating ongoing patient care and discharge planning within healthcare settings.

More about Medical Director Utilization Management jobs
What cities are hiring for Medical Director Utilization Management jobs? Cities with the most Medical Director Utilization Management job openings:
What states have the most Medical Director Utilization Management jobs? States with the most job openings for Medical Director Utilization Management jobs include:
What job categories do people searching Medical Director Utilization Management jobs look for? The top searched job categories for Medical Director Utilization Management jobs are:
Medical Director Utilization Management jobs near you
Infographic showing various Medical Director Utilization Management job openings in the United States as of June 2026, with employment types broken down into 67% Full Time, and 33% Contract. Highlights an 67% In-person, and 33% Remote job distribution, with an average salary of $232,369 per year, or $111.7 per hour.

Medical Director - Utilization Management

Astrana Health, Inc.

Monterey Park, CA • On-site, Remote

$275K - $325K/yr

Full-time

Posted 21 days ago

Job description

Medical Director - Utilization Management
Department: HS - UM
Employment Type: Full Time
Location: 1600 Corporate Center Dr., Monterey Park, CA 91754
Reporting To: Dr. George Christides
Compensation: $275,000 - $325,000 / year
Description
Astrana is seeking a California-licensed Medical Director - Utilization (UM) to provide clinical oversight and strategic leadership through our utilization review operations to ensure members receive high-quality, medically appropriate, and cost-effective care. This is a critical, cross-functional role that bridges clinical expertise with operational execution across value-based care, capitated models, and delegated risk structures.
In this role, you'll apply evidence-based criteria to utilization decisions, mentor clinical review teams, and support compliance with all applicable regulatory and contractual obligations. We are seeking candidates with extensive outpatient UM experience.
This position is ideal for a clinically grounded physician who thrives in a data-informed, team-based environment and is passionate about transforming how care is delivered in a risk-bearing, population health-focused ecosystem.
Our Values:
  • Put Patients First
  • Empower Entrepreneurial Provider and Care Teams
  • Operate with Integrity & Excellence
  • Be Innovative
  • Work As One Team

What You'll Do
Prior Authorization Management
  • Review and issue timely determinations for prior authorization requests, ensuring medical necessity, regulatory compliance, and alignment with evidence-based clinical guidelines.
  • Collaborate with care management and operational teams to streamline and enhance prior authorization workflows for efficiency and provider satisfaction.
  • Provide clinical leadership in the development, implementation, and regular updating of authorization criteria and policies based on the latest medical standards.
  • Promote transparency by clearly documenting and communicating authorization decisions to providers and members, including rationale and guidance for alternative treatment options when applicable.

Utilization Management
  • Provide oversight for the daily activities of the UM program, ensuring services are delivered appropriately and in accordance with clinical best practices.
  • Analyze utilization data to identify trends, high-cost drivers, and opportunities for care optimization and cost containment.
  • Participate in the clinical review of complex or high-cost cases, offering recommendations rooted in medical necessity and member-centered care.
  • Collaborate with interdisciplinary clinical teams to ensure the appropriate use of healthcare resources without compromising quality.

Quality Assurance and Improvement
  • Ensure all UM activities meet applicable federal, state, and accreditation standards (e.g., CMS, NCQA).
  • Lead and contribute to quality improvement initiatives focused on enhancing the effectiveness, accuracy, and consistency of the prior authorization and UM processes.
  • Conduct audits and peer reviews to validate adherence to guidelines and evaluate the quality of medical decision-making.

Provider and Member Communication
  • Serve as the primary clinical contact for complex medical necessity determinations and escalated provider appeals.
  • Build strong working relationships with providers by offering education and clarity around the prior authorization process and criteria.
  • Support member care continuity by suggesting medically appropriate alternatives when requested services are denied.

Regulatory Compliance and Accreditation
  • Ensure full compliance with all applicable UM regulatory and accreditation standards, including NCQA and CMS requirements.
  • Maintain up-to-date knowledge of evolving healthcare laws, policies, and industry standards affecting prior authorization and UM processes.
  • Lead internal efforts to prepare for and maintain UM-related accreditation, including audits, documentation, and process improvement.

Data Analysis and Reporting
  • Monitor and analyze prior authorization and UM metrics (e.g., denial rates, turnaround times, appeal volumes) to identify performance gaps and track progress.
  • Use data-driven insights to inform strategic decisions, improve process efficiency, and support cost management goals.
  • Provide regular updates and reporting to senior leadership on program performance, cost impact, compliance status, and quality indicators.

Qualifications
  • Medical Degree (MD or DO) from an accredited institution; active and unrestricted medical license in CA.
  • Board certification (preferred) in a relevant specialty (e.g., Internal Medicine, Family Medicine, or equivalent).
  • Minimum 5+ years of clinical practice experience.
  • At least 3 years of experience in utilization management or medical management within a health plan, IPA/MSO, or risk-bearing organization.
  • Deep knowledge of managed care, value-based care, capitation, and CMS/Medi-Cal guidelines.
  • Proficient in applying MCG, InterQual, or equivalent criteria.
  • Strong understanding of state and federal regulations (e.g., CMS, DMHC, NCQA).
  • Excellent communication skills, including the ability to engage providers in meaningful, respectful clinical dialogue.
  • Highly collaborative mindset with a commitment to improving healthcare equity, quality, and cost-effectiveness.

Environmental Job Requirements and Working Conditions
  • This position is fully remote, with some travel to SoCal required as needed. Candidates must have a CA medical license.
  • The national target base salary range for this role is: $275,000 - $325,000. Actual compensation will be determined based on geographic location (current or future), experience, or other job-related factors.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

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