UM Medical Director

Medical Director (Utilization Management)

Location: 100% remote, but candidates must be comfortable working PST hours.

Description: The Medical Director (Utilization Management) plays a critical role in leading and supporting the clinical integrity of the utilization management function, with a specific focus on inpatient and post-acute care reviews. This physician leader ensures timely and appropriate care determinations for Medicare Advantage members, guided by clinical criteria, CMS regulations, and evidence-based practices. Reporting to the Chief Medical Officer, this role focuses on evaluating medical necessity and appropriateness of hospital admissions, continued stays, and post-acute services. The Medical Director collaborates with care management teams, providers, and internal stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, and regulatory compliance.

What You Will Do:

• Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, concurrent review, and post-acute care settings (e.g., SNF, IRF, LTACH, home health) for Medicare Advantage members
• Assess appropriateness of acute care services using evidence-based guidelines (e.g., MCG, InterQual) and CMS criteria
• Serve as the physician reviewer for escalated or complex UM cases requiring medical judgment
• Collaborate with utilization management and care management teams to ensure consistent, clinically appropriate, and cost-effective care
• Participate in peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care
• Identify trends in care utilization and support the development of interventions to reduce unnecessary admissions or extended stays
• Provide input into the development and implementation of medical policy and UM protocols
• Support CMS regulatory compliance, audit preparedness, and delegated oversight for UM functions
• Contribute clinical expertise to quality improvement initiatives related to utilization patterns, readmission reduction, and transitions of care
• Document all reviews and decisions according to NCQA, CMS, and organizational requirements
• Participate in UM committee meetings and represent the health plan in external provider and stakeholder engagements as needed

What You Will Bring:

• Licensed M.D. or D.O. in good standing in the state of residence.
• Minimum of 5 years clinical experience, with 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, concurrent review, and Medicare Advantage case reviews and determining medical appropriateness of acute care services
• Knowledge of Medicare Advantage regulations and CMS coverage criteria
• Experience with evidence-based clinical guidelines such as MCG or InterQual
• Effective communication and negotiation skills, particularly in physician-to-physician interactions
• Strong analytical and documentation skills
• Preferred: MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)