Medical Director (Utilization Management)
HJ Staffing
United StatesPosted 17 days agoDiscoveredMatch locked
RemoteFull Time
HJ Staffing
is urgently seeking a
Medical Director of Utilization Management
to join a leading Medicare Advantage Health Plan. This physician leader will play a critical role in ensuring the clinical integrity of inpatient and post-acute care reviews, evaluating medical necessity to support optimal outcomes and regulatory compliance.
Location
100% Remote
Schedule
Full-Time, Monday – Friday (Must work
PST hours
)
Job Description
Reporting to the Chief Medical Officer, the Medical Director focuses on Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members. You will guide timely care determinations using CMS regulations and evidence-based practices (MCG/InterQual) while collaborating with care management teams and external providers.
What You Will Do
•
Clinical Review
Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
•
Criteria Application
Use evidence-based guidelines (
MCG/InterQual
) and CMS criteria to assess the appropriateness of acute care services.
•
Peer-to-Peer
Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
•
Complex Case Management
Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
•
Collaboration
Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings.
•
Compliance & Documentation
Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight.
•
Utilization Trends
Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.
What You Will Bring
•
Credentials
Licensed
M.D. or D.O.
in good standing in your state of residence.
•
Clinical Experience
Minimum of 5 years of clinical experience.
•
Managed Care Expertise
At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
•
Specialized Knowledge
Strong experience in inpatient/post-acute case review and deep knowledge of
Medicare Advantage
regulations and CMS coverage criteria.
•
Technical Skills
Extensive experience with
MCG
guidelines and advanced proficiency in MS Office and medical management software.
•
Education (Preferred)
MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians (
ABQAURP
).
You Will Be Successful If
- You are an expert in using data to design and implement clinical programs and population health management.
- You possess strong negotiation skills, particularly in physician-to-physician interactions.
- You thrive in a matrix organization and can mentor staff while making independent, high-stakes decisions.
- You have a meticulous eye for detail and can maintain a reasonable rate of speed in a fast-paced, high-volume environment.
- You are committed to the highest standards of confidentiality and clinical documentation.
Originally posted on Himalayas
Not included in the source posting: about the role, what you'll do, benefits.
Who can apply
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