Medical Director – Utilization Management
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Job Description
Medical Director managing inpatient and post-acute care reviews for Medicare Advantage Health Plan. Ensuring clinical integrity and compliance with regulations in a fully remote role.
Responsibilities:
- Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
- Use evidence-based guidelines (MCG/InterQual) and CMS criteria to assess the appropriateness of acute care services.
- Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
- Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
- Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings.
- Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight.
- Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.
Requirements:
- Licensed 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 managed care or health plan setting.
- Strong experience in inpatient/post-acute case review and deep knowledge of Medicare Advantage regulations and CMS coverage criteria.
- Extensive experience with MCG guidelines and advanced proficiency in MS Office and medical management software.
- MPH, MBA, or MHA preferred; Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
Benefits:
- Health insurance
- Paid time off
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