Utilization Management Physician Medical Director

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. The Job The Utilization Management (UM) Physician Medical Director provides physician-level clinical leadership and decision-making for the organization's prior authorization, concurrent review, and appeals programs. This role serves as the clinical authority for medical necessity determinations that cannot be approved by RN reviewers, conducts peer-to-peer discussions with treating providers, and partners with UM leadership to ensure the program delivers timely, clinically sound, and cost-effective determinations consistent with evidence-based guidelines, applicable regulatory requirements, and NCQA/URAC accreditation standards. The Medical Director also contributes to program strategy, policy development, quality oversight, and provider education.   Ideally the selected candidate will be local to California. You Will Clinical Review & Determinations   • Perform physician-level medical necessity review of prior authorization requests, concurrent (inpatient) reviews, and retrospective reviews referred by RN reviewers when clinical criteria are not clearly met.   • Render timely determinations consistent with Medicare guidelines, nationally recognized clinical criteria (MCG), evidence-based guidelines, plan policy, standard of care, and applicable state and federal turnaround-time requirements.   • Conduct peer-to-peer discussions with attending physicians and treating providers prior to issuing an adverse determination, and document clinical rationale clearly and defensibly.   • Serve as a physician reviewer for first-level appeals and, where required, refer cases to independent or specialty peer review, participate in ALJ Hearings as required   • Maintain availability for urgent/expedited reviews within required turnaround windows.  Program Leadership & Oversight   • Partner with the UM Director/VP, nursing leadership, Medical Policy, and Grievance and Appeals Department to set clinical review policy, escalation pathways, and criteria adoption/customization.   • Provide clinical guidance and mentorship to RN reviewers and intake staff; serve as a point of escalation for complex or ambiguous cases.   • Participate in interrater reliability (IRR) testing and calibration sessions to ensure consistent application of clinical criteria across the review team.   • Support workforce and capacity planning by advising on case complexity trends, criteria changes, and clinical review time standards.  Quality, Compliance & Accreditation   • Ensure UM decisions and documentation meet NCQA/URAC accreditation standards and applicable state/federal regulatory requirements (e.g., CMS, state DOI/Medicaid rules).   • Participate in the UM Committee, Quality Improvement Committee, and UM Data discussion venues; present clinical outcomes, denial trends, and overturn-rate data.   • Support internal and external audits, regulatory examinations, and delegation oversight reviews related to UM.   • Identify and help remediate patterns of inappropriate utilization, quality-of-care concerns, or potential fraud, waste, and abuse, escalating as appropriate.  Provider Relations & Education   • Communicate professionally and collaboratively with network and non-network providers regarding review determinations and clinical criteria.   • Support provider education on UM policies, submission requirements, and clinical documentation expectations to reduce avoidable denials.   • Represent the UM program in provider disputes, credentialing/quality committees, and external clinical forums as needed.  Supervises/Manages Others ( i.e. hires, performance reviews, corrective action, etc.)    We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the achievement of SCAN’s Vision and Goals.  Other duties as assigned. Your Qualifications Graduate of an accredited medical school required   Required Certifications or Licenses:   Medical License (MD/DO) Experience Required:    Current, active, unrestricted medical license; willingness to obtain additional state licensure as required by the role.  Board certification in good standing in a relevant specialty (e.g., Internal Medicine, Family Medicine, Emergency Medicine).  Minimum of 5 years of active clinical practice experience in Internal Medicine, Family Medicine, or Emergency Medicine. Minimum of 2–3 years of utilization management, case management, or managed care experience, including medical necessity review and peer-to-peer clinical discussions.  Working knowledge of nationally recognized medical necessity criteria (e.g., MCG) and UM regulatory/accreditation frameworks (NCQA, URAC, CMS).  Working knowledge of Medicare decisioning including use of National Coverage Determinations, Local Cove