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.

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

• Conduct clinical reviews to assess medical necessity, treatment appropriateness, and compliance.

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

• Assign appropriate levels of care classifications and conduct continued stay reviews in alignment with CMS and Milliman guidelines.

• Serve as a liaison between the medical team, utilization review, and third-party payers to effectively advocate for suitable levels of medical care.

⛳️ Requirements

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

• Graduation from medical school and completion of a 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.

• Strong attention to detail, along with a commitment to being an effective team member and communicating proficiently with medical staff.

🏝️ Benefits

• Health insurance

• Flexible schedule