Medical Director, Utilization Management

This is a fully remote position, open to applicants in United States.

📋 Description

• Reports to the Senior Vice President of Clinical Operations, with accountability to the Chief Financial Officer and Chief Medical Officer.

• Collaborates with UM licensed personnel, Regional Medical Officers, and Extensivists to create and implement strategies that enhance the utilization of Institutional and Outpatient services for all patients.

• Conducts clinical assessments for medical necessity, treatment appropriateness, and adherence to compliance standards.

• Performs second-level reviews in alignment with Medicare/CMS: NCD, LCD, and Milliman guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care, and Pharmacy.

• Provides accurate level of care classifications and continued stay reviews in accordance with CMS and Milliman guidelines.

• Serves as a liaison among the medical staff, utilization review team, and third-party payers to effectively advocate for appropriate levels of medical care.

⛳️ Requirements

• 3-5 years of experience in a hospital-wide or skilled nursing facility role involving clinical care, quality management, utilization and case management, or medical staff governance is required.

• Must have completed medical school and specialty residency (preferably in internal medicine).

• Board Certification is necessary.

• Current, unrestricted licensure as mandated for clinical practice in the State or US territory where medical decisions are being made.

• Exceptional communication skills are essential.

• Strong attention to detail and a commitment to being a collaborative team member while effectively communicating with medical staff.

🏝️ Benefits

• Health insurance

• Flexible schedule