Medical Director (Utilization Management)
About The Position
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.
Requirements
- 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.
Nice To Haves
- Education (Preferred): MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
Responsibilities
- 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.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Director
Education Level
No Education Listed
