Medical Director – Utilization Management

Now Hiring: Medical Director – Utilization Management100% Remote | Must work PST hoursMedicare Advantage | Inpatient & Post-Acute FocusWe're looking for an experienced Medical Director (Utilization Management) to help lead clinical integrity and medical necessity decision‐making across inpatient and post‐acute care services for Medicare Advantage members .Reporting directly to the Chief Medical Officer , this physician leader will play a key role in ensuring appropriate, evidence‐based, and compliant care decisions that support quality outcomes, cost efficiency, and regulatory excellence.What You'll DoConduct medical necessity reviews for inpatient admissions, continued stays, and post‐acute care (SNF, IRF, LTACH, Home Health)Apply MCG / InterQual guidelines and CMS criteria to utilization decisionsServe as physician reviewer for complex and escalated UM casesParticipate in peer‐to‐peer discussions with attending physiciansPartner with UM and Care Management teams to ensure consistent, cost‐effective careSupport CMS compliance, NCQA standards, audits, and delegated oversightIdentify utilization trends and contribute to quality improvement initiativesAssist in developing medical policies and UM protocolsMaintain accurate clinical documentation per regulatory standardsYou'll Be Successful If You HaveDeep expertise using MCG guidelines in clinical decision‐makingStrong background in inpatient and post‐acute utilization reviewExperience working in managed care or health plan environmentsExcellent analytical, documentation, and negotiation skillsStrong physician‐to‐physician communication abilitiesCollaborative mindset and comfort working in matrix organizationsHigh attention to detail and commitment to confidentiality and complianceWhat You BringMD or DO , licensed and in good standing5+ years of clinical experience , including 3+ years in UM or medical leadershipStrong knowledge of Medicare Advantage regulations & CMS coverage criteriaExperience with MCG or InterQualAdvanced computer skills (MS Office, medical management systems)PreferredMPH, MBA, or MHAABQAURP Certification#J-18808-Ljbffr