Medical Director - Utilization Management & Worker's Compensation

Core Responsibilities (What the Role Does)

Utilization Management Leadership

• 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

Peer-to-peer & Payer Engagement

• 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

Clinical Documentation & Education

• Educate providers on documentation best practices tied to medical necessity and payer criteria
• Identify recurring documentation gaps and implement corrective guidance
• Support audit preparation and response from a clinical perspective

Collaboration & Reporting

• 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

Required Qualifications

• 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 (Strongly Valued)

• 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
• Decision-Making - Timely, confident, and data-informed
• Business Acumen - Understands the financial and compliance implications of utilization decisions

What This Role Is Not

• Not a purely academic or advisory-only position
• Not a full-time practicing clinician role
• Not a compliance-only or check-the-box function

• This role requires ownership, judgment, and real engagement.
• Council Capital and our portfolio companies are committed to building high-performing teams by hiring the best talent-period.
• We believe in putting the right people in the right seats, regardless of background, and we’re always looking for individuals who bring fresh thinking, grit, and a drive to make a difference.
• Thank you for considering a role with one of our companies. We’re excited to learn more about you.