Utilization Review Medical Director
$250,000–$250,000 year
Remote · United States or Troy, Michigan, United States
Job Summary
Utilization Review Medical Director leads real-time clinical reviews of DMEPOS requests, ensuring determinations align with Medicare/Medicaid guidelines, health plan criteria, and NCQA standards. The role requires managing a high-volume authorization review queue, documenting decisions with clear clinical rationale, collaborating with UM staff and external reviewers, supporting audits, and maintaining up-to-date knowledge of relevant policies while serving as a clinical resource for the UM team.
Required Qualifications
- MD or DO degree
- Board certification in Internal Medicine, Family Medicine, or Physical Medicine & Rehabilitation
- Eligible for participation in Medicare, Medicaid, and other federally funded programs; no current or past OIG or state sanctions
- Experience performing utilization management or clinical review activities
- Strong written and verbal communication skills with emphasis on documentation accuracy
- Ability to work effectively in a high-volume, queue-based workflow with daily review expectations
- Familiarity with electronic UM systems and authorization platforms
- Experience with DMEPOS reviews
- Experience with NCQA UM accreditation standards
- Prior UM experience for MLTC, Medicaid, or Medicare Advantage plans
Apply with one swipe on Sorce. We auto-fill applications and apply on your behalf — no cover letters, no 40-minute forms.
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.