Medical Director – Utilization Management

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Perform timely utilization reviews and medical necessity assessments for inpatient admissions and ongoing stays.

• Assess post-acute care services, which include SNF, IRF, LTACH, and home health.

• Evaluate acute and post-acute services utilizing MCG, InterQual, CMS criteria, commercial medical policies, and member benefit plans.

• Implement regulatory and coverage standards based on the member's specific line of business.

• Act as a physician reviewer for escalated, complex, or potentially adverse utilization management cases.

• Engage in peer-to-peer discussions with treating and attending physicians.

• Collaborate with utilization management and care management teams to ensure consistent and cost-effective care.

• Identify utilization trends and support initiatives aimed at reducing avoidable admissions and readmissions.

• Provide clinical insights on medical policies, clinical guidelines, and utilization management protocols.

• Aid in regulatory compliance, audit readiness, accreditation, and delegated oversight tasks.

• Contribute to quality improvement initiatives focused on utilization patterns, readmissions, and care transitions.

• Ensure reviews and determinations are documented in compliance with CMS, NCQA, and relevant state and federal regulations.

• Attend utilization management committee meetings and represent the health plan externally as necessary.

⛳️ Requirements

• Active, unrestricted M.D. or D.O. license in good standing.

• Current board certification in a relevant medical specialty.

• Minimum of 5 years of clinical experience, including at least 3 years in utilization management, physician review, or medical leadership within a managed care or health plan environment.

• Physician-level utilization management experience for Commercial and/or Medicare Advantage populations.

• Extensive experience with inpatient and post-acute care reviews and medical necessity evaluations.

• Understanding of commercial benefits, coverage requirements, and medical policies.

• Familiarity with Medicare Advantage and CMS coverage criteria.

• Experience in applying MCG and/or InterQual guidelines.

• Proven experience in conducting peer-to-peer discussions and conveying complex or adverse determinations.

• Candidate must reside in or possess applicable licensure for New Jersey.

• Preferred: Master's degree such as MPH, MBA, or MHA.

• Preferred: ABQAURP certification.

• Preferred: Experience in quality improvement, regulatory compliance, accreditation, or delegated oversight.

🏝️ Benefits

• Possibility of contract extension.

• Standard business hours schedule.

• Remote work arrangement.