Medical Director – Utilization Management

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

📋 Description

• Report directly to the Senior VP of Clinical Operations, while being accountable to both the Chief Financial Officer and Chief Medical Officer.

• Collaborate with utilization management licensed personnel, Regional Medical Officers, and Extensivists to enhance the use of institutional and outpatient services, ensuring high-quality care.

• Perform remote clinical assessments via the web-based Portal to evaluate medical necessity, treatment appropriateness, and compliance.

• Execute second-level reviews in accordance with Medicare/CMS NCD, LCD, and Milliman guidelines for inpatient, outpatient, skilled-facility level of care, and pharmacy services.

• Deliver level-of-care classifications and conduct continued-stay reviews.

• Facilitate communication among medical staff, utilization review teams, and third-party payers.

• Analyze claim denials, pending claims, appeals, and grievances.

• Act as a physician member of the utilization review team.

• Oversee monitoring of both overutilization and underutilization.

• Create utilization management protocols, including auto-approvals and market-specific protocols, alongside the Interdisciplinary Team.

• Develop educational materials and aid in physicians' annual interrater reliability testing.

• Serve as a subject matter expert for Regional Medical Officers and/or Extensivists during concurrent reviews.

• Lead the Medical Quality Committee and oversee clinical quality outcomes.

• Partner with and support the Quality Director.

• Inform community physicians about utilization management processes and regulations in collaboration with Provider Relations, Network Management, and Regional Medical Officers.

• Encourage physician practices to meet organizational clinical goals.

• Supervise the utilization management clinical staff.

⛳️ Requirements

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

• Graduation from medical school and completion of a specialty residency, ideally in internal medicine.

• Board Certification.

• Active, unrestricted licensure as mandated for clinical practice in the relevant State or US territory where medical decisions are executed.

• Strong understanding of current medical literature, research methodologies, healthcare delivery systems, financial/reimbursement issues, and medical staff organizations.

• Capacity to build strong relationships with medical staff and management leadership to secure approval for utilization management strategies.

• Exceptional communication abilities and meticulous attention to detail.

• Availability Monday through Friday, from 8 AM to 5 PM, with occasional weekend commitments.

🏝️ Benefits

• Fully remote work arrangement.

• Flexible schedule.

• Opportunities for growth and innovation.