Utilization Review Medical Director
New
I
Integra PartnersHealthcare Administration
United States, Standard business hoursContractManager
Salary$150.00/Hourly
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Job Details
Requirements
- MD or DO degree
- Board certification in Internal Medicine, Family Medicine, or Physical Medicine & Rehabilitation
- 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
Responsibilities
- Conduct timely clinical reviews of DMEPOS authorization requests using applicable criteria, including LCDs, Medicaid Manuals, InterQual, MCG, internal medical policies, and health plan requirements.
- Function within a real-time review queue and maintain continuous case throughput in alignment with organizational turnaround and productivity standards.
- Evaluate clinical documentation, identify missing elements, and render determinations supported by clear clinical rationale.
- Review cases escalated by UM staff and/or UM Leadership when criteria do not apply to the enrollee’s unique clinical situation or when clinical judgment is required.
- Participate in Peer-to-Peer (P2P) discussions, including maintaining availability for scheduled appointment times.
- Document all clinical decisions clearly, concisely, and consistently in accordance with internal SOPs, NCQA standards, and regulatory expectations.
- Maintain inter-rater reliability and participate in periodic calibration reviews to support consistency across the UM program.
- Serve as a clinical resource for UM team, providing guidance on clinical interpretation, criteria application, and complex case review.
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