Medical Director – Utilization Management

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

📋 Description

• Assess hospital admissions, ongoing stays, and post-acute services for Medicare Advantage beneficiaries.

• Perform prompt medical necessity evaluations for inpatient admissions and post-acute environments, which include SNF, IRF, LTACH, and Home Health.

• Utilize evidence-based MCG/InterQual guidelines and CMS criteria to evaluate the appropriateness of acute care.

• Facilitate peer-to-peer discussions with attending physicians to clarify clinical documentation and ensure suitable levels of care.

• Act as the primary physician reviewer for escalated or intricate utilization management cases.

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

• Engage in utilization management committee meetings.

• Ensure that decisions are documented in compliance with NCQA and CMS standards.

• Assist in audit readiness and delegated oversight.

• Identify utilization patterns and promote initiatives to minimize unnecessary admissions or prolonged stays.

• Leverage data to create and execute clinical programs and population health management strategies.

• Report directly to the Chief Medical Officer.

⛳️ Requirements

• Licensed M.D. or D.O. in good standing in the candidate's state of residence.

• A minimum of 5 years of clinical experience.

• At least 3 years in a utilization management or medical leadership position within a managed care or health plan environment.

• Strong background in inpatient/post-acute case review.

• In-depth understanding of Medicare Advantage regulations and CMS coverage criteria.

• Extensive familiarity with MCG guidelines.

• Advanced skills in MS Office and medical management software.

• Preferred: MPH, MBA, or MHA.

• Preferred: Certification from the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).

• Exceptional negotiation skills, especially in physician-to-physician interactions.

• Ability to excel in a matrix organization and mentor staff while making independent, high-stakes decisions.

• Keen attention to detail and capability to maintain a reasonable pace in a fast-paced, high-volume setting.

• Dedication to confidentiality and clinical documentation standards.

• Must be available to work PST hours.

🏝️ Benefits

• Full-time schedule from Monday to Friday.

• 100% remote work opportunity.