Medical Director (Utilization Management) - Remote

Overview

The Medical Director (Utilization Management) plays a critical role in leading and supporting the clinical integrity of the utilization management function, with a specific focus on inpatient and post-acute care reviews. This physician leader ensures timely and appropriate care determinations for Medicare Advantage members, guided by clinical criteria, CMS regulations, and evidence-based practices.

In Short

• Conduct timely utilization review and medical necessity determinations for inpatient admissions and post-acute care.
• Assess appropriateness of acute care services using evidence-based guidelines.
• Collaborate with care management teams to ensure consistent, clinically appropriate care.
• Participate in peer-to-peer discussions with attending physicians.
• Identify trends in care utilization and develop interventions.
• Support CMS regulatory compliance and audit preparedness.
• Contribute clinical expertise to quality improvement initiatives.
• Document all reviews according to NCQA, CMS, and organizational requirements.
• Participate in UM committee meetings.
• Represent the health plan in external engagements as needed.

Requirements

• Licensed M.D. or D.O. in good standing.
• Minimum of five years clinical experience with three years in a utilization management role.
• Strong experience in inpatient and post-acute case review.
• Knowledge of Medicare Advantage regulations and CMS coverage criteria.
• Experience with evidence-based clinical guidelines.
• Effective communication and negotiation skills.
• Strong analytical and documentation skills.
• Preferred: MPH, MBA, or MHA; Certification by ABQAURP.

Benefits

• Competitive salary.
• Comprehensive health benefits.
• Opportunities for professional development.
• Supportive work environment.
• Flexible working arrangements.