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Medical Director (Utilization Management)

๐Ÿ•’ 3 days ago
Clinical ReviewUtilization ManagementCMS RegulationsEvidence-based Guidelines

๐Ÿ“œ Description

  • 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.
  • Partner with utilization and care management teams to ensure consistent, cost-effective care.

๐Ÿ› ๏ธ 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.

โœจ Benefits

  • Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
  • Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
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๐Ÿ“… Apr 30

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