DescriptionThe 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, consistent, and appropriate care determinations for Commercial and Medicare Advantage members based on applicable benefit plans, medical policies, clinical criteria, CMS regulations, and evidence-based practices.
Reporting to the Chief Medical Officer, this role evaluates the medical necessity and appropriateness of hospital admissions, continued stays, and post-acute services. The Medical Director collaborates with utilization management and care management teams, providers, and internal stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, regulatory compliance, and the appropriate application of member benefits.
What You Will Do - Conduct timely utilization reviews and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings, including SNF, IRF, LTACH, and home health, for Commercial and Medicare Advantage members.
- Assess the appropriateness of acute and post-acute services using evidence-based guidelines, including MCG and InterQual, as well as applicable CMS criteria, Commercial medical policies, coverage guidelines, and member benefit plans.
- Apply the appropriate regulatory and coverage standards based on the member's line of business.
- Serve as the physician reviewer for escalated, complex, or potentially adverse utilization management cases requiring medical judgment.
- Collaborate with utilization management and care management teams to promote consistent, clinically appropriate, and cost-effective care.
- Participate in peer-to-peer discussions with treating and attending physicians to clarify clinical documentation and support appropriate levels of care.
- Identify trends in care utilization and support interventions designed to reduce avoidable admissions, readmissions, extended stays, and unnecessary healthcare expenditures.
- Provide clinical input into the development, interpretation, and implementation of medical policies, clinical guidelines, and utilization management protocols.
- Support regulatory compliance, audit preparedness, accreditation requirements, and delegated oversight for Commercial and Medicare Advantage utilization management functions.
- Contribute clinical expertise to quality improvement initiatives involving utilization patterns, readmission reduction, care transitions, and member outcomes.
- Document all reviews, determinations, and clinical rationales in accordance with CMS, NCQA, applicable state and federal requirements, and organizational policies.
- Participate in utilization management committee meetings and represent the health plan in provider, regulatory, and external stakeholder engagements as needed.
You Will Be Successful If You Have - Extensive knowledge of MCG guidelines and their application in clinical decision-making.
- Working knowledge of InterQual or other nationally recognized clinical criteria.
- Knowledge of Commercial health plan coverage requirements, medical policies, benefit structures, and utilization management practices.
- Knowledge of Medicare Advantage regulations, CMS coverage criteria, and applicable regulatory requirements.
- Experience using medical management systems and software that support utilization management and other clinical activities.
- Experience in population health management and using data to design and implement clinical programs.
- Experience working with different levels of staff in a matrixed organization.
- Strong analytical, assessment, problem-solving, and negotiation skills.
- The ability to establish and maintain effective working relationships with individuals at all levels inside and outside the organization.
- Effective oral and written communication skills, including the ability to explain complex clinical and coverage determinations clearly.
- A demonstrated ability to promote collaboration and teamwork.
- The ability to supervise and mentor staff, analyze situations independently, and make appropriate clinical decisions.
- The ability to prepare written reports and maintain accurate records in compliance with state and federal clinical documentation and privacy requirements.
- Advanced proficiency with Microsoft Office products and related business applications.
- A demonstrated commitment to protecting confidential patient, business, and employee information.
- Strong attention to detail and the ability to work accurately while meeting required productivity and turnaround-time standards.
What You Will Bring - An M.D. or D.O. degree with an active, unrestricted medical license in good standing in the state of residence.
- Current board certification in an appropriate medical specialty.
- A minimum of five years of clinical experience, including at least three years in utilization management, physician review, or medical leadership within a managed care or health plan setting.
- Physician-level utilization management experience supporting Commercial and/or Medicare Advantage populations.
- Strong experience conducting inpatient and post-acute case reviews and determining the medical necessity and appropriateness of acute and post-acute services.
- Knowledge of Commercial health plan benefits, coverage guidelines, medical policies, and applicable state and federal requirements.
- Knowledge of Medicare Advantage regulations and CMS coverage criteria.
- Experience applying evidence-based clinical guidelines such as MCG or InterQual.
- Experience conducting peer-to-peer discussions and communicating adverse or complex clinical determinations.
- Strong analytical, clinical documentation, communication, and physician-to-physician negotiation skills.
- Preferred: MPH, MBA, or MHA.
- Preferred: Certification by the American Board of Quality Assurance and Utilization Review Physicians.
