Medical Director (Utilization Management)

HJ Staffing

1d • Remote

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.

Requirements

• Licensed M.D. or D.O. in good standing in your state of residence.
• Minimum of 5 years of clinical experience.
• At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
• Strong experience in inpatient/post-acute case review and deep knowledge of Medicare Advantage regulations and CMS coverage criteria.
• Extensive experience with MCG guidelines and advanced proficiency in MS Office and medical management software.

Nice To Haves

• MPH, MBA, or MHA
• Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
• Expert in using data to design and implement clinical programs and population health management.
• Strong negotiation skills, particularly in physician-to-physician interactions.
• Ability to thrive in a matrix organization and can mentor staff while making independent, high-stakes decisions.
• Meticulous eye for detail and can maintain a reasonable rate of speed in a fast-paced, high-volume environment.
• Committed to the highest standards of confidentiality and clinical documentation.

Responsibilities

• Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
• Use evidence-based guidelines (MCG/InterQual) and CMS criteria to assess the appropriateness of acute care services.
• Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
• Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
• Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings.
• Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight.
• Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Ph.D. or professional degree