Medical Director

1 day ago

Houston, TX, United States Bickham Services Unlimited, LLC Full time

Title: Medical Director (Utilization Management)
Location: Remote - candidates must be comfortable working PST hours
Start Date: Monday, November 10, 2025
Position Type: Contract

Assignment Details

The Medical Director (Utilization Management) plays a key leadership role in ensuring the clinical integrity of the utilization management (UM) function, with a particular focus on inpatient and post-acute care reviews. Reporting to the Chief Medical Officer, this physician leader will ensure care determinations are clinically appropriate, compliant with CMS regulations, and aligned with evidence-based guidelines.

Key Responsibilities

  • Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care services (SNF, IRF, LTACH, home health) for Medicare Advantage members.
  • Apply MCG and InterQual guidelines as well as CMS criteria to assess the appropriateness of acute care services.
  • Serve as the physician reviewer for complex or escalated UM cases requiring clinical judgment.
  • Collaborate with utilization and care management teams to ensure consistent, cost-effective, and patient-centered care decisions.
  • Participate in peer-to-peer discussions with attending physicians to clarify documentation and support proper levels of care.
  • Identify utilization trends and assist in developing interventions to reduce unnecessary admissions or extended stays.
  • Contribute to the development and implementation of medical policy and UM protocols.
  • Support CMS regulatory compliance, audit preparedness, and delegated oversight activities.
  • Participate in UM committee meetings and represent the organization in provider or stakeholder engagements.
  • Ensure all documentation meets NCQA, CMS, and internal standards.
Qualifications

Required:
  • Licensed M.D. or D.O., in good standing in the state of residence.
  • Minimum 5 years of clinical experience, including 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
  • Strong knowledge of Medicare Advantage regulations and CMS coverage criteria.
  • Experience with MCG and InterQual guidelines.
  • Excellent communication, analytical, and negotiation skills.
  • Proficiency with MS Office and medical management systems.
  • Ability to maintain strict confidentiality and adhere to HIPAA and organizational standards.
Preferred:
  • MPH, MBA, or MHA.
  • Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
You'll Excel In This Role If You Have:
  • Deep knowledge of MCG criteria and evidence-based utilization management.
  • Experience leveraging data to design population health and clinical improvement programs.
  • Strong interpersonal skills with the ability to engage effectively across matrixed teams.
  • Proven ability to drive collaboration, mentor clinical staff, and ensure compliance with state and federal documentation standards.
  • Exceptional attention to detail and the ability to make sound, timely medical decisions.

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