Medical Director, Utilization Management – Commercial & MA

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

📋 Description

• Perform timely utilization reviews and assessments of medical necessity for inpatient admissions, ongoing stays, and post-acute care environments, including skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), long-term acute care hospitals (LTACH), and home health services for Commercial and Medicare Advantage members.

• Evaluate the appropriateness of acute and post-acute services utilizing evidence-based guidelines, including MCG and InterQual, along with relevant CMS criteria, Commercial medical policies, coverage guidelines, and member benefit plans.

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

• Act as the physician reviewer for escalated, complex, or potentially adverse utilization management cases that necessitate medical judgment.

• Collaborate with utilization management and care management teams to ensure consistent, clinically appropriate, and cost-effective care delivery.

• Engage in peer-to-peer discussions with treating and attending physicians to clarify clinical documentation and ensure appropriate levels of care are maintained.

• Identify patterns in care utilization and support initiatives aimed at reducing preventable admissions, readmissions, prolonged stays, and avoidable healthcare costs.

• Provide clinical insights into the creation, interpretation, and execution of medical policies, clinical guidelines, and utilization management protocols.

• Support adherence to regulatory compliance, audit readiness, accreditation standards, and delegated oversight for Commercial and Medicare Advantage utilization management functions.

• Contribute clinical knowledge to quality enhancement initiatives related to utilization patterns, readmission reductions, care transitions, and member outcomes.

• Record all reviews, determinations, and clinical rationales in line with CMS, NCQA, relevant state and federal regulations, and organizational policies.

• Attend utilization management committee meetings and represent the health plan in provider, regulatory, and external stakeholder interactions as necessary.

⛳️ Requirements

• Experience in utilization management for Commercial and/or Medicare Advantage populations.

• A minimum of five years of clinical experience, including at least three years in utilization management, physician review, or medical leadership within a managed care or health plan environment.

• An M.D. or D.O. degree with a valid, unrestricted medical license in good standing in the state of residence.

• Current board certification in an appropriate medical specialty.

• Extensive experience in conducting inpatient and post-acute case reviews and assessing the medical necessity and appropriateness of acute and post-acute services.

• Familiarity with Commercial health plan benefits, coverage guidelines, medical policies, and relevant state and federal regulations.

• Understanding of Medicare Advantage regulations and CMS coverage criteria.

• Proven experience applying evidence-based clinical guidelines such as MCG or InterQual.

• Experience in conducting peer-to-peer discussions and effectively communicating adverse or complex clinical determinations.

🏝️ Benefits

• Fully remote opportunity

• Immediate start