Medical Director – Utilization Management

HJ Staffing · via Get Backend Jobs

🌎 Remote ⌛ Posted 12 days ago

Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members
Conduct timely medical necessity determinations for inpatient admissions and post-acute settings, including SNF, IRF, LTACH, and Home Health
Apply MCG/InterQual evidence-based guidelines and CMS criteria to assess acute care services
Lead peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care
Serve as primary physician reviewer for escalated or complex utilization management cases
Collaborate with utilization and care management teams to ensure consistent, cost-effective care
Participate in utilization management committee meetings
Document decisions according to NCQA and CMS requirements
Support audit preparedness and delegated oversight
Identify utilization trends and support interventions to reduce unnecessary admissions or extended stays
Use data to design and implement clinical programs and population health management initiatives
Report to the Chief Medical Officer

Licensed M.D. or D.O. in good standing in the candidate’s 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
Deep knowledge of Medicare Advantage regulations and CMS coverage criteria
Extensive experience with MCG guidelines
Advanced proficiency in MS Office and medical management software
Strong negotiation skills, particularly in physician-to-physician interactions
Ability to work in a matrix organization and mentor staff
Ability to make independent, high-stakes decisions
Meticulous attention to detail and ability to maintain a reasonable rate of speed in a fast-paced, high-volume environment
Commitment to confidentiality and clinical documentation standards