Utilization Review Medical Director

Integra Partners•Troy, MI

2d•Remote

About The Position

The Utilization Review Medical Director is responsible for conducting clinical reviews of Durable Medical Equipment (DME) and related requests to support Integra’s Utilization Management (UM) operations. This full-time, salaried role functions within a structured, high-volume authorization review queue and requires adherence to workflow timelines, clinical accuracy standards, and productivity expectations. The Medical Director ensures determinations are made in accordance with Medicare and Medicaid guidelines, health plan–specific criteria, internal policies, and regulatory requirements. This role is best suited for physicians who thrive in a process-driven environment and are committed to consistency, compliance, and evidence-based decision making.

Requirements

MD or DO degree
Board certification in Internal Medicine, Family Medicine, or Physical Medicine & Rehabilitation
Eligible for participation in Medicare, Medicaid, and other federally funded programs; no current or past OIG or state sanctions
Experience performing utilization management or clinical review activities
Strong written and verbal communication skills with emphasis on documentation accuracy
Ability to work effectively in a high-volume, queue-based workflow with daily review expectations
Familiarity with electronic UM systems and authorization platforms
Experience with DMEPOS reviews
Experience with NCQA UM accreditation standards
Prior UM experience for MLTC, Medicaid, or Medicare Advantage plans

Responsibilities

Conduct timely clinical reviews of DMEPOS authorization requests using applicable criteria, including LCDs, Medicaid Manuals, InterQual, MCG, internal medical policies, and health plan requirements.
Function within a real-time review queue and maintain continuous case throughput in alignment with organizational turnaround and productivity standards.
Evaluate clinical documentation, identify missing elements, and render determinations supported by clear clinical rationale.
Review cases escalated by UM staff and/or UM Leadership when criteria do not apply to the enrollee’s unique clinical situation or when clinical judgment is required.
When appropriate, consult with external board-certified reviewers, engage with ordering practitioners, or conduct additional clinical dialogue prior to rendering a determination.
Participate in Peer-to-Peer (P2P) discussions, including maintaining availability for scheduled appointment times.
Document all clinical decisions clearly, concisely, and consistently in accordance with internal SOPs, NCQA standards, and regulatory expectations.
Maintain inter-rater reliability and participate in periodic calibration reviews to support consistency across the UM program.
Serve as a clinical resource for UM team, providing guidance on clinical interpretation, criteria application, and complex case review.
Support internal and external audit activities as needed, including NCQA accreditation, health plan audits, and state Medicaid reviews.
Notify leadership of observed trends, potential quality concerns, or opportunities to strengthen criteria alignment or operational workflows.
Maintain up-to-date knowledge of Medicare, Medicaid, DMEPOS policies, clinical standards of care, and regulatory updates relevant to UM.