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 members.

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

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

• Facilitate peer-to-peer discussions with attending physicians to enhance clinical documentation and ensure appropriate care levels.

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

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

• Engage in utilization management committee meetings.

• Record decisions in compliance with NCQA and CMS standards.

• Assist in audit preparedness and oversee delegated responsibilities.

• Recognize utilization patterns and support initiatives aimed at minimizing unnecessary admissions or prolonged stays.

• Report directly to the Chief Medical Officer.

⛳️ Requirements

• Must possess a valid M.D. or D.O. license in good standing within your state of residence.

• A minimum of 5 years of clinical experience is required.

• 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 reviews.

• Comprehensive understanding of Medicare Advantage regulations and CMS coverage guidelines.

• Extensive familiarity with MCG guidelines.

• Advanced skills in MS Office and medical management software.

• Proficient use of data to create and implement clinical programs and manage population health.

• Excellent negotiation skills, especially in physician-to-physician discussions.

• Capacity to excel in a matrix organization and mentor team members.

• Ability to make independent, high-stakes decisions.

• Exceptional attention to detail while maintaining efficiency in a fast-paced, high-volume setting.

• Strong commitment to confidentiality and adherence to clinical documentation standards.

• MPH, MBA, or MHA is preferred.

• Certification from ABQAURP is preferred.

🏝️ Benefits

• Full-time schedule, Monday–Friday.

• 100% remote work availability.

• Opportunity to join a leading Medicare Advantage Health Plan.

• Involvement in UM committee meetings.

• Opportunity to mentor staff and make independent, high-stakes decisions.