What are the responsibilities and job description for the Medical Director (Utilization Management) position at HJ Staffing?
We’re looking for a Medical Director (Utilization Management) to guide clinical integrity in utilization management, focusing on inpatient and post-acute care reviews for Medicare Advantage members.
What You’ll Do:
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Conduct utilization reviews and determine medical necessity for admissions and post-acute services.
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Apply evidence-based guidelines (MCG, InterQual) and CMS criteria.
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Collaborate with providers and UM/care management teams.
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Participate in peer-to-peer reviews and UM committee meetings.
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Support compliance, audits, and quality improvement initiatives.
What You’ll Bring:
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Licensed M.D. or D.O. (in good standing).
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5 years clinical experience; 3 years in UM/medical leadership in managed care.
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Strong knowledge of Medicare Advantage regulations and CMS coverage.
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Familiarity with MCG/InterQual criteria.
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Preferred: MPH, MBA, MHA, or ABQAURP certification.