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Medical Director – Utilization Management

Appworkshub
Full-time
Remote
United States
Case Management Care Management, Utilization Management Utilization Review, Quality

🚨 Now Hiring: Medical Director – Utilization Management
🕒 100% Remote | Must work PST hours
🏥 Medicare Advantage | Inpatient & Post-Acute Focus

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