Medical Director – Utilization Management

Now Hiring: Medical Director – Utilization Management 100% Remote | Must work PST hours Medicare Advantage | Inpatient & Post-Acute FocusWe’re looking for an experiencedMedical Director (Utilization Management)to help lead clinical integrity and medical necessity decision‑making across inpatient and post‑acute care services forMedicare Advantage members .Reporting directly to theChief Medical Officer , this physician leader will play a key role in ensuringappropriate, evidence‑based, and compliant care decisionsthat support quality outcomes, cost efficiency, and regulatory excellence.What You’ll DoConduct medical necessity reviews forinpatient admissions, continued stays, and post‑acute care(SNF, IRF, LTACH, Home Health)ApplyMCG / InterQual guidelinesand CMS criteria to utilization decisionsServe as physician reviewer forcomplex and escalated UM casesParticipate inpeer‑to‑peer discussionswith attending physiciansPartner with UM and Care Management teams to ensure consistent, cost‑effective careSupportCMS compliance, NCQA standards, audits, and delegated oversightIdentify utilization trends and contribute toquality improvement initiativesAssist in developingmedical policies and UM protocolsMaintain accurate clinical documentation per regulatory standardsYou’ll Be Successful If You HaveDeep expertise usingMCG guidelinesin clinical decision‑makingStrong background ininpatient and post‑acute utilization reviewExperience working inmanaged care or health plan environmentsExcellent analytical, documentation, and negotiation skillsStrong physician‑to‑physician communication abilitiesCollaborative mindset and comfort working inmatrix organizationsHigh attention to detail and commitment to confidentiality and complianceWhat You BringMD or DO , licensed and in good standing5+ years of clinical experience , including3+ years in UM or medical leadershipStrong knowledge ofMedicare Advantage regulations & CMS coverage criteriaExperience withMCG or InterQualAdvanced computer skills (MS Office, medical management systems)⭐PreferredMPH, MBA, or MHAABQAURP Certification#J-18808-Ljbffr