Medical Director
2 weeks ago
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.
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.
- MPH, MBA, or MHA.
- Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
- 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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