Medical Director - Utilization

Application Deadline: 30 September 2025

Department: HS - Providers

Location: 600 City Parkway West 10th Floor, Orange, CA 92868

Description

As Medical Director - Utilization (UM) at Astrana Health, you will provide clinical oversight and strategic leadership across 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.

You’ll work closely with teams in Care Management, Quality Improvement, Pharmacy, Behavioral Health, and Compliance to drive aligned decision-making that supports both optimal patient outcomes and efficient healthcare resource use. 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.

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.

What You'll Do

Clinical & Operational Leadership

• Lead clinical review of prior authorizations, concurrent hospitalizations, and post-service claims to ensure medical necessity and appropriateness of care.
• Apply standardized evidence-based guidelines (e.g., MCG, InterQual, CMS NCD/LCDs) to all utilization decisions.
• Serve as a medical resource and final reviewer for escalated and complex cases.

Cross-Functional Collaboration

• Partner with Care Management on discharge planning, transitions of care, and high-risk case review.
• Collaborate with Pharmacy, Behavioral Health, and Social Work teams to coordinate whole-person care and reduce fragmentation.
• Support Quality Improvement efforts by identifying utilization trends and helping design interventions that promote high-value care.

Compliance & Appeals

• Participate in clinical reviews of member/provider appeals and grievances.
• Ensure timely documentation and adherence to regulatory turnaround times.
• Support audits by CMS, DHCS, and delegated health plans by maintaining compliant UM policies and practices.

Data-Driven Strategy

• Analyze patterns in service utilization, high-cost claims, and provider practice variation to inform population health strategies.
• Provide clinical input into policy and protocol development that aligns with value-based goals.

Provider Engagement

• Conduct peer-to-peer discussions with treating providers to explain UM decisions and foster understanding of clinical rationale.
• Support network performance reviews and provider education initiatives related to utilization trends.
  
  

Qualifications

• Medical Degree (MD or DO) from an accredited institution; active and unrestricted medical license in CA.
• Board certification 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 Remote - US Based
• The target base salary range for this role is: $250,000 - $300,000. This salary range represents our national target range for this role

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.