Medical Director (Utilization Management)
New
H
HJ StaffingHealth Plan
United States, PSTFull-TimeDirector
Salary not disclosed
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Job Details
- Experience
- Minimum of 5 years of clinical experience.
Requirements
- Active M.D. or D.O. license in good standing in your state of residence.
- Minimum of 5 years of clinical experience.
- At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
- Strong experience in inpatient and post-acute case review.
- Deep knowledge of Medicare Advantage regulations and CMS coverage criteria.
- Extensive experience using MCG or InterQual guidelines.
- Advanced proficiency in MS Office and medical management software.
- Ability to work full-time during PST hours.
Responsibilities
- Conduct timely medical necessity determinations for inpatient admissions and post-acute settings including SNF, IRF, LTACH, and Home Health.
- Assess the appropriateness of acute care services using evidence-based guidelines like MCG/InterQual and CMS criteria.
- Lead peer-to-peer discussions with attending physicians to clarify documentation and support appropriate levels of care.
- Serve as the primary physician reviewer for escalated or complex utilization management cases.
- Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in committee meetings.
- Maintain documentation compliance according to NCQA and CMS requirements and support audit preparedness.
- Identify care patterns to support interventions that reduce unnecessary admissions or extended stays.
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