Remote Insurance Utilization Review Jobs in Pittsburgh, PA

Job Summary

The Medical Director is responsible for ensuring utilization management activities are conducted in accordance with current clinical standards, regulatory requirements, and organizational policies. Working as part of a multidisciplinary physician team, this role reviews escalated medical cases, evaluates medical necessity and appropriateness of requested services, and supports appeals and grievance determinations. The position also provides physician leadership for case and disease management initiatives while contributing to process improvements, protocol development, and regulatory compliance activities.

Primary responsibilities include conducting utilization reviews and peer-to-peer discussions, supporting multidisciplinary care management teams, and assisting with clinical policy and operational improvement initiatives. This role is critical in maintaining high-quality patient care standards, regulatory compliance, and effective medical management practices within the organization.

Key Responsibilities

• Conduct electronic utilization reviews of escalated cases using established medical policy criteria and clinical guidelines to determine medical necessity and appropriateness of care.
• Perform initial determinations, appeals, grievances, and additional case reviews as assigned.
• Conduct telephonic peer-to-peer discussions with treating providers when required.
• Prepare clear, concise, and compliant clinical rationales and determination notifications.
• Ensure compliance with NCQA, URAC, CMS, DOH, DOL, and other applicable regulatory standards.
• Participate as a physician member of multidisciplinary case and disease management teams.
• Attend clinical huddles, grand rounds, and interdisciplinary care discussions.
• Provide physician expertise and recommendations on complex or high-risk cases.
• Assist in the development and maintenance of utilization review protocols, policies, and clinical guidelines.
• Support special projects and operational initiatives requiring physician subject matter expertise.
• Collaborate with clinical, operational, and compliance teams to improve care management processes.
• Maintain productivity expectations, including high-volume case review requirements.
• Utilize clinical review systems and software applications to manage utilization review activities.
• Participate in quality improvement initiatives and continuous process enhancement efforts.

Minimum Education & Experience Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited institution.
• Minimum of 5 years of direct clinical patient care experience in hospital, outpatient, or private practice settings.
• Board Certification in a specialty recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA).
• Active unrestricted medical license in at least one of the following states: Pennsylvania, New York, or West Virginia.
• Minimum of 1 year of experience in utilization management, medical management, or payer-side managed care preferred.
• Experience reviewing medical necessity determinations, appeals, and grievances preferred.
• Prior experience within a health insurance plan or managed care organization strongly preferred.

Special Requirements

• Must be a United States citizen.
• Ability to successfully complete required Medical Director Assessment.
• Ability to work remotely in a secure home office environment.
• Ability to maintain productivity standards, including reviewing high daily case volumes.
• Flexibility to support Eastern Standard Time core business hours.
• Experience with MCG, InterQual, or similar utilization review criteria tools preferred.
• Behavioral Health or Non-Behavioral Health (Physical Health) utilization management experience may be required depending on assignment.

Knowledge, Skills, and Abilities

• Strong knowledge of utilization management principles and payer-side medical management operations.
• Understanding of NCQA, URAC, CMS, DOH, and DOL regulations and compliance standards.
• Experience conducting peer-to-peer clinical reviews and medical necessity determinations.
• Excellent clinical judgment and critical thinking skills.
• Strong written and verbal communication abilities.
• Proficiency with clinical software systems and electronic medical review platforms.
• Experience with utilization management systems such as Predictal, Beacon, or similar platforms preferred.
• Ability to manage multiple priorities and work efficiently in a high-volume review environment.
• Strong collaboration and interdisciplinary communication skills.
• Effective documentation and case rationale writing skills.
• Ability to analyze complex clinical information and apply evidence-based guidelines.
• Strong organizational, time management, and problem-solving abilities.
• Proficiency with general computer applications and remote work technologies.

Additional Desired Characteristics

• Master’s degree in Business Administration, Healthcare Administration, or Public Health preferred.
• Experience supporting Behavioral Health utilization management initiatives.
• Prior Medical Director or Physician Advisor experience within a payer organization.
• Familiarity with value-based care models and population health management.
• Experience participating in quality improvement or operational transformation initiatives.
• Strong understanding of managed care operations and healthcare reimbursement models.

Work Environment

• Fully remote work environment.
• Standard schedule consists of 40 hours per week with core business hours aligned to Eastern Time.
• Flexible scheduling may be available after completion of onboarding and training.
• Position may require participation in virtual meetings, peer-to-peer calls, and multidisciplinary team discussions.
• Fast-paced, high-volume clinical review environment with productivity expectations.
• Contract position with potential for full-time conversion.

Other Duties

This job description is not intended to be an exhaustive list of all responsibilities, duties, or qualifications associated with the position. Additional duties and responsibilities may be assigned based on organizational needs.