Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
Use evidence-based guidelines (MCG/InterQual) and CMS criteria to assess the appropriateness of acute care services.
Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings.
Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight.
Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.

Licensed M.D. or D.O. in good standing in your state of residence.
Minimum of 5 years of clinical experience.
At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
Strong experience in inpatient/post-acute case review and deep knowledge of Medicare Advantage regulations and CMS coverage criteria.
Extensive experience with MCG guidelines and advanced proficiency in MS Office and medical management software.
MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) preferred.

Medical Director (Utilization Management)

Key skills