Medical Director (Utilization Management

Position Overview

• Title: Medical Director (Utilization Management)
• Location: Remote (must reside on the West Coast; PST hours)
• Start Date: Mon, Sep 8, 2025
• Contract: 6 months
• Reports To: Chief Medical Officer

Purpose:
Lead and ensure clinical integrity of utilization management (UM) processes, focusing on inpatient and post-acute care reviews, ensuring timely, appropriate, and evidence-based care for Medicare Advantage members.

Key Responsibilities

1. Utilization Review & Medical Necessity
   • Conduct reviews for inpatient admissions, continued stays, and post-acute care (SNF, IRF, LTACH, home health).
   • Use evidence-based guidelines (MCG, InterQual) and CMS criteria to assess appropriateness.
   • Serve as physician reviewer for complex or escalated UM cases.
2. Collaboration & Communication
   • Work closely with UM and care management teams to ensure clinically appropriate, cost-effective care.
   • Conduct peer-to-peer discussions with attending physicians to clarify documentation.
   • Represent the health plan in provider/stakeholder engagements.
3. Analysis & Quality Improvement
   • Identify utilization trends and support interventions to reduce unnecessary admissions or extended stays.
   • Contribute to policy development, UM protocols, and quality improvement initiatives (readmission reduction, transitions of care).
4. Regulatory Compliance & Documentation
   • Ensure compliance with CMS, NCQA, and internal standards.
   • Maintain accurate documentation and records according to regulatory requirements.

Required Skills & Competencies

• Expertise in MCG guidelines and medical management software.
• Experience in population health management and designing clinical programs.
• Ability to work effectively in a matrix organization and across multiple staff levels.
• Strong analytical, problem-solving, negotiation, and interpersonal skills.
• Effective oral and written communication; ability to explain complex information.
• Ability to supervise/mentor staff and maintain confidentiality of sensitive information.
• Proficiency in MS Office and other computer systems.
• Strong attention to detail and accuracy.

Required Experience & Qualifications

• Medical License: M.D. or D.O. in good standing in state of residence.
• Clinical Experience: Minimum 5 years, with at least 3 in UM or medical leadership within managed care or health plan.
• Clinical Skills: Inpatient and post-acute case review, determining appropriateness of acute care.
• Regulatory Knowledge: Medicare Advantage regulations, CMS coverage criteria.
• Guideline Knowledge: Evidence-based clinical guidelines (MCG, InterQual).
• Preferred: MPH, MBA, MHA, or ABQAURP certification.

Summary

This is a remote, West Coast–based, 6-month contract for an experienced physician with strong UM leadership experience. The role emphasizes clinical decision-making, compliance, collaboration, and quality improvement in the Medicare Advantage population.