Medical Director (Utilization Management)
# Medical Director (Utilization Management) **HJ Staffing** · United States · `Remote` · `Full Time` 💼 **Уровень роли:** `Director` 🕒 **Статус:** *Опубликовано: сегодня* · *Источник: Himalayas (JSON API)* --- ### Top Skills & Match 🎯 **Ключевой стек роли:** `[Medical-Director]` `[Utilization-Management-Physician]` `[Physician-Advisor]` `[UR-UM-Medical-Director]` `[Managed-Care-Medical-Director]` `[Medical-Director-Utilization-Management]` `[Utilization-Management-Director]` `[Utilization-Management-Leadership]` `[Utilization-Review-Director]` --- ### About the Role 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 - Clinical Review: Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health). - Criteria Application: Use evidence-based guidelines ( MCG/InterQual ) and CMS criteria to assess the appropriateness of acute care services. - Peer-to-Peer: Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care. - Complex Case Management: Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment. - Collaboration: Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings. - Compliance & Documentation: Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight. - Utilization Trends: Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays. What You Will Bring - Credentials: Licensed M.D. or D.O. in good standing in your state of residence. - Clinical Experience: Minimum of 5 years of clinical experience. - Managed Care Expertise: At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting. - Specialized Knowledge: Strong experience in inpatient/post-acute case review and deep knowledge of Medicare Advantage regulations and CMS coverage criteria. - Technical Skills: Extensive experience with MCG guidelines and advanced proficiency in MS Office and medical management software. - 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
- Medical-Director
- Utilization-Management-Physician
- Physician-Advisor
- UR-UM-Medical-Director
- Managed-Care-Medical-Director
- Medical-Director-Utilization-Management
- Utilization-Management-Director
- Utilization-Management-Leadership
- Utilization-Review-Director
Наблюдалась 2026-10-04, впервые 2026-10-04, источник — Himalayas (JSON API).