Medical Director – Utilization Management
A
AppworkshubHealthcare
Listing locations: USA; 100% Remote, Must work PST hoursFull-TimeSenior
Salary not disclosed
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Job Details
- Experience
- 5+ years of clinical experience, including 3+ years in UM or medical leadership
- Required Skills
- MS Office
Requirements
- Hold an MD or DO degree and be licensed and in good standing.
- Have 5+ years of clinical experience, including 3+ years in utilization management or medical leadership.
- Have strong expertise using MCG guidelines in clinical decision-making.
- Have a strong background in inpatient and post-acute utilization review.
- Have experience working in managed care or health plan environments.
- Have strong knowledge of Medicare Advantage regulations and CMS coverage criteria.
- Have experience with MCG or InterQual.
- Have advanced computer skills, including MS Office and medical management systems.
- Preferred: MPH, MBA, or MHA.
- Preferred: ABQAURP Certification.
Responsibilities
- Conduct medical necessity reviews for inpatient admissions, continued stays, and post-acute care, including SNF, IRF, LTACH, and Home Health.
- Apply MCG or InterQual guidelines and CMS criteria to utilization decisions.
- Review complex and escalated utilization management cases as a physician reviewer.
- Participate in peer-to-peer discussions with attending physicians.
- Partner with UM and Care Management teams to support 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 in accordance with regulatory standards.
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