Medical Director (Utilization Management

Accountabilities Conduct timely medical necessity reviews for inpatient admissions, continued stays, and post-acute services, including skilled nursing facilities, inpatient rehabilitation facilities, long-term acute care hospitals, and home health.

Apply evidence-based clinical guidelines, including MCG and InterQual, alongside CMS requirements to determine appropriate levels and settings of care.

Evaluate complex clinical cases and provide expert medical judgment for escalated utilization management decisions.

Lead peer-to-peer discussions with attending physicians to clarify clinical documentation, communicate determinations, and support appropriate levels of care.

Collaborate closely with utilization management and care management teams to promote consistent, clinically appropriate, and cost-effective care decisions.

Participate in utilization management committee meetings and contribute physician-level expertise to clinical and operational initiatives.

Ensure utilization decisions are accurately documented and aligned with CMS and NCQA requirements.

Support audit readiness, regulatory compliance, and oversight activities related to utilization management programs.

Analyze utilization trends and identify patterns that may indicate opportunities to reduce unnecessary admissions, avoidable services, or extended inpatient stays.

Use clinical and utilization data to support the design and implementation of clinical programs and population health management initiatives.

Mentor and support clinical staff while contributing to a collaborative, matrixed operating environment.

Maintain strict confidentiality and uphold high standards for clinical documentation, professional judgment, and patient care.

Requirements

Active, unrestricted M.D. or D.O. license in good standing in the state of residence.

Minimum of 5 years of clinical experience.

At least 3 years of experience in utilization management, medical leadership, managed care, or a health plan environment.

Strong experience conducting inpatient and post-acute clinical reviews and making medical necessity determinations.

Deep knowledge of Medicare Advantage requirements, CMS regulations, and applicable coverage criteria.

Extensive experience applying MCG guidelines; familiarity with InterQual is also valuable.

Strong understanding of utilization management principles, care management practices, and post-acute levels of care.

Excellent physician-to-physician communication and negotiation skills, with the ability to navigate challenging clinical discussions professionally.

Strong analytical and decision-making capabilities, particularly when evaluating complex or high-stakes clinical cases.

Ability to work independently while collaborating effectively within a matrixed organization.

Strong attention to detail and the ability to maintain accuracy and appropriate productivity in a fast-paced, high-volume environment.

Proficiency with Microsoft Office and medical management or utilization management software.

Strong commitment to confidentiality, regulatory compliance, and high-quality clinical documentation.

MPH, MBA, or MHA is preferred.

ABQAURP certification is preferred.

Experience using clinical and utilization data to develop clinical programs or population health strategies is preferred.

Benefits

Fully remote position within the United States.

Full-time, Monday–Friday schedule aligned with Pacific Time.

Physician leadership opportunity within a Medicare Advantage utilization management environment.

Opportunity to influence clinical quality, medical necessity, care coordination, and utilization outcomes.

Ability to work with multidisciplinary clinical, utilization management, and care management teams.

Opportunity to contribute to clinical programs, population health initiatives, and utilization improvement strategies.

Professional environment emphasizing evidence-based decision-making, regulatory compliance, and patient-centered care.

Opportunities to mentor clinical staff and contribute to broader medical management initiatives.

How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best!  Why Apply Through Jobgether? 

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