Medical Director – Utilization Management

We’re looking for an experienced Medical Director (Utilization Management) to help lead clinical integrity and medical necessity decision-making across inpatient and post-acute care services for Medicare Advantage members.

Reporting directly to the Chief Medical Officer, this physician leader will play a key role in ensuring appropriate, evidence-based, and compliant care decisions that support quality outcomes, cost efficiency, and regulatory excellence.

🔑 What You’ll Do

• Conduct medical necessity reviews for inpatient admissions, continued stays, and post-acute care (SNF, IRF, LTACH, Home Health)

• Apply MCG / InterQual guidelines and CMS criteria to utilization decisions

• Serve as physician reviewer for complex and escalated UM cases

• Participate in peer-to-peer discussions with attending physicians

• Partner with UM and Care Management teams to ensure consistent, cost-effective care

• Support CMS compliance, NCQA standards, audits, and delegated oversight

• Identify utilization trends and contribute to quality improvement initiatives

• Assist in developing medical policies and UM protocols

• Maintain accurate clinical documentation per regulatory standards

🎯 You’ll Be Successful If You Have

• Deep expertise using MCG guidelines in clinical decision-making

• Strong background in inpatient and post-acute utilization review

• Experience working in managed care or health plan environments

• Excellent analytical, documentation, and negotiation skills

• Strong physician-to-physician communication abilities

• Collaborative mindset and comfort working in matrix organizations

• High attention to detail and commitment to confidentiality and compliance

🩺 What You Bring

• MD or DO, licensed and in good standing

• 5+ years of clinical experience, including 3+ years in UM or medical leadership

• Strong knowledge of Medicare Advantage regulations & CMS coverage criteria

• Experience with MCG or InterQual

• Advanced computer skills (MS Office, medical management systems)

⭐ Preferred

• MPH, MBA, or MHA

• ABQAURP Certification