Medical Director (Utilization Management)

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.

Location: 100% Remote

Schedule: Full-Time, Monday – Friday (Must work PST hours )

Job Description

Reporting to the Chief Medical Officer, the Medical Director focuses on Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members. You will guide timely care determinations using CMS regulations and evidence-based practices (MCG/InterQual) while collaborating with care management teams and external providers.

What You Will Do

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Clinical Review: Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).

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Criteria Application: Use evidence-based guidelines ( MCG/InterQual ) and CMS criteria to assess the appropriateness of acute care services.

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Peer-to-Peer: Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.

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Complex Case Management: Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.

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Collaboration: Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings.

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Compliance & Documentation: Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight.

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Utilization Trends: Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.

What You Will Bring

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Credentials: Licensed M.D. or D.O. in good standing in your state of residence.

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Clinical Experience: Minimum of 5 years of clinical experience.

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Managed Care Expertise: At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.

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Specialized Knowledge: Strong experience in inpatient/post-acute case review and deep knowledge of Medicare Advantage regulations and CMS coverage criteria.

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Technical Skills: Extensive experience with MCG guidelines and advanced proficiency in MS Office and medical management software.

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Education (Preferred): MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians ( ABQAURP ).

You Will Be Successful If:

- You are an expert in using data to design and implement clinical programs and population health management.

- You possess strong negotiation skills, particularly in physician-to-physician interactions.

- You thrive in a matrix organization and can mentor staff while making independent, high-stakes decisions.

- You have a meticulous eye for detail and can maintain a reasonable rate of speed in a fast-paced, high-volume environment.

- You are committed to the highest standards of confidentiality and clinical documentation.

Originally posted on Himalayas