Medical Director Utilization Management

We are seeking a **Medical Director of Utilization Management** to lead and support the clinical integrity of our utilization management (UM) functions, with a primary focus on inpatient and post-acute care reviews. In this role, you will ensure timely, consistent, and appropriate care determinations for Commercial and Medicare Advantage members. By leveraging evidence-based practices, CMS regulations, and health plan benefit structures, you will evaluate the medical necessity of care, participate in peer-to-peer consultations, and collaborate with multidisciplinary teams to drive optimal clinical outcomes, regulatory compliance, and cost efficiency. **Duration:** August 10, 2026 – February 10, 2027 **Location:** Henderson, NV _(100% Fully Remote Opportunity)_ **Reporting To:** Chief Medical Officer **Start Date:** Immediate Need ### **Key Responsibilities** * **Utilization Review & Medical Necessity:** Conduct timely medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings (SNF, IRF, LTACH, Home Health) for Commercial and Medicare Advantage populations. * **Evidence-Based Evaluation:** Apply nationally recognized guidelines (MCG, InterQual), CMS coverage criteria, and health plan policies to ensure appropriate level-of-care determinations. * **Complex Case Escalation:** Serve as the lead physician reviewer for complex, high-risk, or potentially adverse UM cases requiring clinical judgment. * **Peer-to-Peer Engagement:** Conduct peer-to-peer discussions with attending and treating physicians to clarify documentation, discuss options, and align on appropriate care plans. * **Cross-Functional Collaboration:** Partner with Care Management and UM teams to identify utilization trends, reduce avoidable readmissions/extended stays, and streamline care transitions. * **Policy & Quality Support:** Offer clinical expertise to support quality improvement initiatives, regulatory audit preparedness (CMS/NCQA), policy development, and UM committee activities. * **Documentation & Compliance:** Maintain precise, compliant, and timely documentation of all reviews and rationales in accordance with federal, state, and organizational guidelines. ### **Must-Have Qualifications** * **Education & Licensure:** Active M.D. or D.O. degree with an active, unrestricted medical license in good standing (in state of residence). * **Board Certification:** Current Board Certification in an appropriate medical specialty. * **Clinical & Leadership Experience:** Minimum of **5 years of clinical practice**, including at least **3 years of direct experience** in utilization management, physician review, or medical leadership within a managed care or health plan setting. * **Population Expertise:** Demonstrated physician-level experience supporting **Commercial and/or Medicare Advantage** lines of business. ### **What Will Make You Successful** * **Criteria Proficiency:** Advanced expertise with **MCG guidelines** and strong working knowledge of **InterQual** and **CMS criteria**. * **Regulatory Knowledge:** Deep understanding of Medicare Advantage regulations, Commercial health plan benefit structures, and state/federal UM mandates. * **Technical Skills:** Experience navigating medical management platforms, enterprise applications, and Microsoft Office products. * **Communication & Negotiation:** Exceptional written and oral communication skills, with a proven ability to handle delicate peer-to-peer discussions and articulate complex clinical rationales clearly. * **Analytical Mindset:** Strong problem-solving abilities, attention to detail, and a data-driven approach to identifying utilization trends and quality gaps. ### **Preferred Qualifications** * Master’s degree in Public Health, Business Administration, or Health Administration (**MPH, MBA, or MHA**). * Certification by the American Board of Quality Assurance and Utilization Review Physicians (**ABQAURP**). ### **Why Apply?** This is a **100% remote, high-impact contract opportunity** starting immediately, offering you the flexibility of working from home while managing key clinical determinations for a dynamic health plan environment. Originally posted on [Himalayas](https://himalayas.app)