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, including Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), Long-Term Acute Care Hospitals (LTACH), and Home Health.

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

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

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

• Work in collaboration with utilization and care management teams to guarantee consistent, cost-effective care.

• Engage in utilization management committee meetings.

• Record decisions in compliance with NCQA and CMS standards.

• Assist in audit readiness and delegated oversight.

• Recognize utilization trends and promote interventions to decrease unnecessary admissions or prolonged stays.

• Leverage data to design and execute clinical programs and population health management initiatives.

• Report directly to the Chief Medical Officer.

⛳️ Requirements

• An M.D. or D.O. license 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.

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

• Significant experience with MCG guidelines.

• Advanced skills in MS Office and medical management software.

• Excellent negotiation abilities, especially in physician-to-physician interactions.

• Capability to work within a matrix organization and mentor staff.

• Aptitude for making independent, high-stakes decisions.

• Exceptional attention to detail and ability to maintain a swift pace in a high-volume, fast-paced environment.

• Dedication to confidentiality and adherence to clinical documentation standards.

🏝️ Benefits

• Full-time schedule from Monday to Friday.

• 100% remote work opportunity.