Medical Director – Utilization Management

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

📋 Description

• Perform timely evaluations of medical necessity for inpatient admissions and post-acute care settings, which include SNF, IRF, LTACH, and Home Health.

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

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

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

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

• Take part in utilization management committee meetings.

• Ensure that decisions are documented in accordance with NCQA and CMS requirements.

• Assist in audit readiness and delegated oversight.

• Identify trends in utilization and advocate for interventions aimed at reducing unnecessary admissions or extended stays.

• Guide staff and make independent, high-stakes clinical decisions within a matrix organization.

⛳️ Requirements

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

• At least 5 years of clinical experience is required.

• A minimum of 3 years in a utilization management or medical leadership role within a managed care or health plan environment is necessary.

• Strong background in inpatient and post-acute case review is essential.

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

• Extensive familiarity with MCG guidelines is necessary.

• Advanced proficiency in MS Office and medical management software is expected.

• Possession of an MPH, MBA, or MHA is preferred.

• ABQAURP certification is preferred.

• Proven expertise in using data to design and implement clinical programs and manage population health.

• Strong negotiation skills for interactions between physicians are a must.

• Ability to thrive in a matrix organization, mentor staff, and make independent high-stakes decisions is essential.

• Exceptional attention to detail and capacity to work efficiently in a dynamic, high-volume environment are required.

• A commitment to confidentiality and clinical documentation is necessary.

• Must be available to work PST hours.

🏝️ Benefits

• Competitive salary and comprehensive health benefits.

• Opportunities for professional development and continuing education.

• Supportive work environment with a focus on work-life balance.

• Participation in innovative projects and initiatives within the healthcare sector.