Medical Director (Utilization Management)
New
H
HJ StaffingMedicare Advantage health plan
Location: United States; 100% Remote, Must work PST hoursFull-TimeDirector
Salary not disclosed
Apply NowOpens the employer's application page
Job Details
- Experience
- 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.
- Required Skills
- MS Office
Requirements
- Hold an M.D. or D.O. license in good standing in your state of residence.
- Have a minimum of 5 years of clinical experience.
- Have at least 3 years of experience in utilization management or medical leadership within a managed care or health plan setting.
- Bring strong experience in inpatient and post-acute case review.
- Have deep knowledge of Medicare Advantage regulations and CMS coverage criteria.
- Have extensive experience with MCG guidelines.
- Have advanced proficiency in MS Office and medical management software.
- Preferred: MPH, MBA, or MHA.
- Preferred: Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
- Work full-time, Monday through Friday, during PST hours.
Responsibilities
- Make timely medical necessity determinations for inpatient admissions and post-acute settings, including SNF, IRF, LTACH, and Home Health.
- Apply MCG/InterQual guidelines and CMS criteria to assess the appropriateness of acute care services.
- Lead peer-to-peer discussions with attending physicians to clarify clinical 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 support consistent, cost-effective care.
- Participate in utilization management committee meetings.
- Document decisions according to NCQA and CMS requirements and support audit preparedness and delegated oversight.
- Identify utilization patterns and support interventions to reduce unnecessary admissions or extended stays.
View Full Description & ApplyYou'll be redirected to the employer's site
