Medical Director (Utilization Management)

Reporting to the Chief Medical Officer, the Medical Director focuses on Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members. You will guide timely care determinations using CMS regulations and evidence-based practices (MCG/InterQual) while collaborating with care management teams and external providers.

• →Clinical Review: Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
• →Criteria Application: Use evidence-based guidelines (MCG/InterQual) and CMS criteria to assess the appropriateness of acute care services.
• →Peer-to-Peer: Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
• →Complex Case Management: Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
• →Collaboration: Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings.
• →Compliance & Documentation: Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight.
• →Utilization Trends: Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.

• →Credentials: Licensed M.D. or D.O. in good standing in your state of residence.
• →Clinical Experience: Minimum of 5 years of clinical experience.
• →Managed Care Expertise: At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
• →Specialized Knowledge: Strong experience in inpatient/post-acute case review and deep knowledge of Medicare Advantage regulations and CMS coverage criteria.
• →Technical Skills: Extensive experience with MCG guidelines and advanced proficiency in MS Office and medical management software.
• →Education (Preferred): MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).

• You are an expert in using data to design and implement clinical programs and population health management.
• You possess strong negotiation skills, particularly in physician-to-physician interactions.
• You thrive in a matrix organization and can mentor staff while making independent, high-stakes decisions.
• You have a meticulous eye for detail and can maintain a reasonable rate of speed in a fast-paced, high-volume environment.
• You are committed to the highest standards of confidentiality and clinical documentation.