Medical Director - Utilization Management

Medical Director - Utilization Management

Department: HS - UM

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Dr. Dinesh Kumar

Compensation: $275000 - 325000

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

Prior Authorization Management

• Review and issue timely determinations for prior authorization requests, ensuring medical necessity, regulatory compliance, and alignment with evidence-based clinical guidelines.
• Collaborate with care management and operational teams to streamline and enhance prior authorization workflows for efficiency and provider satisfaction.
• Provide clinical leadership in the development, implementation, and regular updating of authorization criteria and policies based on the latest medical standards.
• Promote transparency by clearly documenting and communicating authorization decisions to providers and members, including rationale and guidance for alternative treatment options when applicable.

Utilization Management

• Provide oversight for the daily activities of the UM program, ensuring services are delivered appropriately and in accordance with clinical best practices.
• Analyze utilization data to identify trends, high-cost drivers, and opportunities for care optimization and cost containment.
• Participate in the clinical review of complex or high-cost cases, offering recommendations rooted in medical necessity and member-centered care.
• Collaborate with interdisciplinary clinical teams to ensure the appropriate use of healthcare resources without compromising quality.

Quality Assurance and Improvement

• Ensure all UM activities meet applicable federal, state, and accreditation standards (e.g., CMS, NCQA).
• Lead and contribute to quality improvement initiatives focused on enhancing the effectiveness, accuracy, and consistency of the prior authorization and UM processes.
• Conduct audits and peer reviews to validate adherence to guidelines and evaluate the quality of medical decision-making.

Provider and Member Communication

• Serve as the primary clinical contact for complex medical necessity determinations and escalated provider appeals.
• Build strong working relationships with providers by offering education and clarity around the prior authorization process and criteria.
• Support member care continuity by suggesting medically appropriate alternatives when requested services are denied.

Regulatory Compliance and Accreditation

• Ensure full compliance with all applicable UM regulatory and accreditation standards, including NCQA and CMS requirements.
• Maintain up-to-date knowledge of evolving healthcare laws, policies, and industry standards affecting prior authorization and UM processes.
• Lead internal efforts to prepare for and maintain UM-related accreditation, including audits, documentation, and process improvement.

Data Analysis and Reporting

• Monitor and analyze prior authorization and UM metrics (e.g., denial rates, turnaround times, appeal volumes) to identify performance gaps and track progress.
• Use data-driven insights to inform strategic decisions, improve process efficiency, and support cost management goals.
• Provide…