Medical Director (Utilization Management)

Bickham Services Unlimited, LLC•Houston, TX

42d•Remote

About The Position

The Medical Director (Utilization Management) plays a key leadership role in ensuring the clinical integrity of the utilization management (UM) function, with a particular focus on inpatient and post-acute care reviews. Reporting to the Chief Medical Officer, this physician leader will ensure care determinations are clinically appropriate, compliant with CMS regulations, and aligned with evidence-based guidelines.

Requirements

Licensed M.D. or D.O., in good standing in the state of residence.
Minimum 5 years of clinical experience, including 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
Strong knowledge of Medicare Advantage regulations and CMS coverage criteria.
Experience with MCG and InterQual guidelines.
Excellent communication, analytical, and negotiation skills.
Proficiency with MS Office and medical management systems.
Ability to maintain strict confidentiality and adhere to HIPAA and organizational standards.

Nice To Haves

MPH, MBA, or MHA.
Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
Deep knowledge of MCG criteria and evidence-based utilization management.
Experience leveraging data to design population health and clinical improvement programs.
Strong interpersonal skills with the ability to engage effectively across matrixed teams.
Proven ability to drive collaboration, mentor clinical staff, and ensure compliance with state and federal documentation standards.
Exceptional attention to detail and the ability to make sound, timely medical decisions.

Responsibilities

Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care services (SNF, IRF, LTACH, home health) for Medicare Advantage members.
Apply MCG and InterQual guidelines as well as CMS criteria to assess the appropriateness of acute care services.
Serve as the physician reviewer for complex or escalated UM cases requiring clinical judgment.
Collaborate with utilization and care management teams to ensure consistent, cost-effective, and patient-centered care decisions.
Participate in peer-to-peer discussions with attending physicians to clarify documentation and support proper levels of care.
Identify utilization trends and assist in developing interventions to reduce unnecessary admissions or extended stays.
Contribute to the development and implementation of medical policy and UM protocols.
Support CMS regulatory compliance, audit preparedness, and delegated oversight activities.
Participate in UM committee meetings and represent the organization in provider or stakeholder engagements.
Ensure all documentation meets NCQA, CMS, and internal standards.