Medical Director – Utilization Management
New
USA, PSTFull-TimeDirector
Salary not disclosed
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Job Details
- Experience
- 5+ years of clinical experience, including 3+ years in UM or medical leadership
Requirements
- MD or DO, licensed and in good standing
- 5+ years of clinical experience
- 3+ years in UM or medical leadership
- Strong knowledge of Medicare Advantage regulations & CMS coverage criteria
- Experience with MCG or InterQual
- Advanced computer skills (MS Office, medical management systems)
- Excellent analytical, documentation, and negotiation skills
- Strong physician-to-physician communication abilities
- Collaborative mindset and comfort working in matrix organizations
Responsibilities
- Conduct medical necessity reviews for inpatient admissions, continued stays, and post-acute care (SNF, IRF, LTACH, Home Health)
- Apply MCG / InterQual guidelines and CMS criteria to utilization decisions
- Serve as physician reviewer for complex and escalated UM cases
- Participate in peer-to-peer discussions with attending physicians
- Partner with UM and Care Management teams to ensure consistent, cost-effective care
- Support CMS compliance, NCQA standards, audits, and delegated oversight
- Identify utilization trends and contribute to quality improvement initiatives
- Assist in developing medical policies and UM protocols
- Maintain accurate clinical documentation per regulatory standards
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