Medical Director Utilization Management

The role

Physicians with Internal Medicine expertise will determine the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. The role involves conducting medical reviews, peer-to-peer discussions, and supporting clinical content teams.

What you will do

• Support the clinical content team in reviewing clinical decision guidelines and evidence based literature
• Provide expert input on content for influencing physicians in medical care
• Provide timely medical reviews that meet quality and timeliness parameters
• Provide clinical determinations based on evidence-based criteria
• Document all communication and decision-making in workflow tools
• Use correct templates for documenting medical necessity decisions
• Conduct timely peer-to-peer discussions with treating providers
• Support projects specific to building the team's clinical expertise and efficiency
• Support the team on operational improvements and member/provider experience

Required qualifications

• Completed US-based residency program and fellowship in Internal Medicine
• Board certification as an MD or DO
• Current unrestricted state license to practice medicine
• 5+ years of clinical practice beyond residency/fellowship in Internal Medicine
• Excels in a matrix organization
• Comfortable with technology
• Understanding of managed care regulatory structure and processes
• Detail-oriented, flexible, and able to work autonomously

Nice to have

• 1+ years of managed care utilization review experience desirable
• Membership in national and/or regional specialty societies preferred
• Licensure in AZ, GA, MS, NC, ND, OK, OR, or TX is highly desirable

Benefits

• Medical, dental, vision, life, disability insurance, and Employee Assistance Program
• 401K retirement plan with company match
• flexible spending and health savings account
• Flex Time Off + company holidays
• Up to 14 weeks of paid parental leave
• Pet insurance

Before you apply

• Reviewers must maintain necessary credentials to retain the position
• Preliminary Phone Screening
• Meet your Hiring Manager
• Behavioral Interview(s)

About the company

Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs. The company improves collaboration and reduces burden, resulting in up to 8x ROI and 94% provider satisfaction.