What are the responsibilities and job description for the Medical Director (Utilization Management position at Bickham Services Unlimited, LLC?
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
- 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.
- 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.
- 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).
- 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.