Job Description
About the Role The Part‑Time Medical Director – Utilization Management, Outpatient Services provides physician oversight for medical necessity, appropriateness, and utilization decisions across Astrana Health ’s outpatient, ancillary, and professional services. This role supports Astrana’s delegated risk arrangements by ensuring compliant, evidence‑based utilization while partnering closely with outpatient clinical leadership, UM operations, and health plan stakeholders. What You'll Do Provide physician oversight and final determination for outpatient utilization management activities, including prior authorizations, retrospective reviews, and appeals. Ensure medical necessity and appropriateness of outpatient services such as specialty referrals, diagnostics, imaging, DME, therapies, and procedures. Support compliance with delegated health plan requirements, regulatory standards, and accreditation guidelines. Conduct peer‑to‑peer reviews and outpatient physician education to improve documentation, guideline adherence, and appropriate utilization. Partner with Outpatient Medical Directors, Population Health, and UM nursing teams to align utilization decisions with Astrana’s value‑based care strategy. Identify outpatient utilization trends, leakage, and variation; recommend clinical strategies to improve cost efficiency and quality outcomes. Serve as clinical liaison with health plans and external vendors on outpatient UM‑related matters. Qualifications MD or DO; Board Certified in Internal Medicine, Family Medicine, or a relevant outpatient specialty required. Active, unrestricted medical license (California required). Prior experience in outpatient utilization management, health plan medical management, or delegated risk environments. Strong understanding of outpatient medical necessity criteria, prior authorization workflows, and appeals processes. Experience working with PCPs and ambulatory specialists in value‑based care models. Strong physician‑to‑physician com
