Medical Director, Utilization Management (Commercial & MA)
RemoteUnited States
Job Summary
Conduct timely utilization reviews and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings including SNF, IRF, LTACH, and home health for Commercial and Medicare Advantage members. Assess service appropriateness using evidence-based guidelines like MCG and InterQual, serve as the physician reviewer for escalated complex cases, and participate in peer-to-peer discussions with treating physicians. Identify utilization trends to support interventions reducing avoidable admissions and expenditures while providing clinical input on medical policy development. Collaborate with care management teams to ensure regulatory compliance, audit preparedness, and optimal member outcomes. Fully remote contract role starting immediately with a 6-9 month term.
Required Qualifications
- Utilization management experience supporting Commercial and/or Medicare Advantage populations
- Minimum of five years of clinical experience, including at least three years in utilization management, physician review, or medical leadership within a managed care or health plan setting
- An M.D. or D.O. degree with an active, unrestricted medical license in good standing in the state of residence
- Current board certification in an appropriate medical specialty
- Physician-level utilization management experience supporting Commercial and/or Medicare Advantage populations
- Strong experience conducting inpatient and post-acute case reviews and determining the medical necessity and appropriateness of acute and post-acute services
- Knowledge of Commercial health plan benefits, coverage guidelines, medical policies, and applicable state and federal requirements
- Knowledge of Medicare Advantage regulations and CMS coverage criteria
- Experience applying evidence-based clinical guidelines such as MCG or InterQual
- Experience conducting peer-to-peer discussions and communicating adverse or complex clinical determinations
- Strong analytical, clinical documentation, communication, and physician-to-physician negotiation skills
- Advanced proficiency with Microsoft Office products and related business applications
- A demonstrated commitment to protecting confidential patient, business, and employee information
- Strong attention to detail and the ability to work accurately while meeting required productivity and turnaround-time standards
- Must be able to lift 50 lbs
Desired Qualifications
- Extensive knowledge of MCG guidelines and their application in clinical decision-making
- Working knowledge of InterQual or other nationally recognized clinical criteria
- Experience using medical management systems and software that support utilization management and other clinical activities
- Experience in population health management and using data to design and implement clinical programs
- Experience working with different levels of staff in a matrixed organization
- Strong analytical, assessment, problem-solving, and negotiation skills
- The ability to establish and maintain effective working relationships with individuals at all levels inside and outside the organization
- Effective oral and written communication skills, including the ability to explain complex clinical and coverage determinations clearly
- A demonstrated ability to promote collaboration and teamwork
- The ability to supervise and mentor staff, analyze situations independently, and make appropriate clinical decisions
- The ability to prepare written reports and maintain accurate records in compliance with state and federal clinical documentation and privacy requirements
- Preferred: MPH, MBA, or MHA
- Preferred: Certification by the American Board of Quality Assurance and Utilization Review Physicians
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