Medical Director

The Medical Director (Utilization Management) plays a critical role in leading and supporting the clinical integrity of the utilization management function, with a specific focus on inpatient and post-acute care reviews. This physician leader ensures timely and appropriate care determinations for Medicare Advantage members, guided by clinical criteria, CMS regulations, and evidence-based practices.

Reporting to the Chief Medical Officer, this role focuses on evaluating medical necessity and appropriateness of hospital admissions, continued stays, and post-acute services. The Medical Director collaborates with care management teams, providers, and internal stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, and regulatory compliance.

What You Will Do:

Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings (e.g., SNF, IRF, LTACH, home health) for Medicare Advantage members

Assess appropriateness of acute care services using evidence-based guidelines (e.g., MCG, InterQual) and CMS criteria

Serve as the physician reviewer for escalated or complex UM cases requiring medical judgment

Collaborate with utilization management and care management teams to ensure consistent, clinically appropriate, and cost-effective care

Participate in peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care

Identify trends in care utilization and support the development of interventions to reduce unnecessary admissions or extended stays

Provide input into the development and implementation of medical policy and UM protocols

Support CMS regulatory compliance, audit preparedness, and delegated oversight for UM functions

Contribute clinical expertise to quality improvement initiatives related to utilization patterns, readmission reduction, and transitions of care

Document all reviews and decisions according to NCQA, CMS, and organizational requirements

Participate in UM committee meetings and represent the health plan in external provider and stakeholder engagements as needed

You Will Be Successful If:

Extensive knowledge of the use of MCG guidelines in clinical decision making.

Knowledge of medical management systems and software to support clinical actives in Health services.

Experience in population health management and use of data to design and implement clinical programs.

Experience working with different levels of staff in a matrix organization.

Strong analytical, problem-solving skills with good negotiation skills.

Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of the organization.

Effective oral and written communication skills, including the ability to effectively explain complex information and documents according to clinical standards.

Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork.

Ability to supervise and mentor staff, analyze situations independently and make appropriate decisions.

Ability to prepare written reports and maintain accurate records in compliance with State and federal requirements for clinical documentation and privacy rules.

Strong analytical, assessment and problem-solving skills with intermediate negotiation skills.

Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of the organization.

Advanced computer skills that include MS Office products.

Demonstrate ability to respect and maintain the confidentiality of all sensitive documents, records, discussions, and other information generated in connection with activities conducted in, or related to, patient healthcare, business or employee information and make no disclosure of such information except as required in the conduct of business.

Strong attention to detail; work accurately and at a reasonable rate of speed.

What You Will Bring:

Licensed M.D. or D.O. in good standing in the state of residence.

Minimum of five (5) years clinical experience, with at least three (3) years in a utilization management or medical leadership role within a managed care or health plan setting

Strong experience in inpatient and post-acute case review and determining medical appropriateness of acute care services

Knowledge of Medicare Advantage regulations and CMS coverage criteria

Experience with evidence-based clinical guidelines such as MCG or InterQual

Effective communication and negotiation skills, particularly in physician-to-physician interactions

Strong analytical and documentation skills

Preferred: MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)