Medical Director
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Job Description
UM Medical Director overseeing clinical integrity for utilization management. Focus on inpatient and post-acute care reviews for Medicare Advantage members in compliance with regulations.
Responsibilities:
- Conduct clinical reviews for inpatient admissions and post-acute settings using evidence-based guidelines (MCG, InterQual) and CMS criteria
- Serve as the primary physician reviewer for escalated or complex cases requiring high-level medical judgment
- Engage in peer-to-peer discussions with attending physicians to clarify clinical documentation and support the appropriate level of care
- Partner with care management teams to identify utilization trends and develop interventions to reduce unnecessary admissions or extended stays
- Ensure all decisions are documented in strict accordance with NCQA, CMS, and organizational standards
- Contribute expertise to initiatives focused on readmission reduction and transitions of care
Requirements:
- M.D. or D.O. in good standing in your state of residence
- Minimum of 5 years of clinical experience
- At least 3 years in a Utilization Management or medical leadership role within a health plan setting
- Strong experience with Medicare Advantage case reviews and CMS coverage criteria
- Preferred: MPH, MBA, or MHA; Certification by the ABQAURP
Benefits:
- Health insurance
- Paid time off
- Professional development opportunities
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