Medical Director, Utilization Management (Commercial & MA)

HJ Staffing•Henderson, NV

3d•Remote

About The Position

We are seeking a Medical Director of Utilization Management to lead and support the clinical integrity of our utilization management (UM) functions, with a primary focus on inpatient and post-acute care reviews. In this role, you will ensure timely, consistent, and appropriate care determinations for Commercial and Medicare Advantage members. By leveraging evidence-based practices, CMS regulations, and health plan benefit structures, you will evaluate the medical necessity of care, participate in peer-to-peer consultations, and collaborate with multidisciplinary teams to drive optimal clinical outcomes, regulatory compliance, and cost efficiency.

Requirements

Active M.D. or D.O. degree with an active, unrestricted medical license in good standing (in state of residence).
Current Board Certification in an appropriate medical specialty.
Minimum of 5 years of clinical practice, including at least 3 years of direct experience in utilization management, physician review, or medical leadership within a managed care or health plan setting.
Demonstrated physician-level experience supporting Commercial and/or Medicare Advantage lines of business.
Advanced expertise with MCG guidelines and strong working knowledge of InterQual and CMS criteria.
Deep understanding of Medicare Advantage regulations, Commercial health plan benefit structures, and state/federal UM mandates.
Experience navigating medical management platforms, enterprise applications, and Microsoft Office products.
Exceptional written and oral communication skills, with a proven ability to handle delicate peer-to-peer discussions and articulate complex clinical rationales clearly.
Strong problem-solving abilities, attention to detail, and a data-driven approach to identifying utilization trends and quality gaps.

Nice To Haves

Master’s degree in Public Health, Business Administration, or Health Administration (MPH, MBA, or MHA).
Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).

Responsibilities

Conduct timely medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings (SNF, IRF, LTACH, Home Health) for Commercial and Medicare Advantage populations.
Apply nationally recognized guidelines (MCG, InterQual), CMS coverage criteria, and health plan policies to ensure appropriate level-of-care determinations.
Serve as the lead physician reviewer for complex, high-risk, or potentially adverse UM cases requiring clinical judgment.
Conduct peer-to-peer discussions with attending and treating physicians to clarify documentation, discuss options, and align on appropriate care plans.
Partner with Care Management and UM teams to identify utilization trends, reduce avoidable readmissions/extended stays, and streamline care transitions.
Offer clinical expertise to support quality improvement initiatives, regulatory audit preparedness (CMS/NCQA), policy development, and UM committee activities.
Maintain precise, compliant, and timely documentation of all reviews and rationales in accordance with federal, state, and organizational guidelines.