Medical Director (Utilization Management)

📋 Description

• Evaluate inpatient admissions, continued stays, and post-acute services
• Apply CMS requirements and evidence-based guidelines (MCG, InterQual)
• Provide expert medical judgment for escalation in utilization decisions
• Lead physician discussions to clarify documentation and care levels
• Collaborate with UM and care teams for cost-effective decisions
• Contribute to clinical programs and population health initiatives

🎯 Requirements

• Active, unrestricted MD or DO license in state of residence
• Minimum 5 years of clinical experience
• At least 3 years in utilization management or health plan setting
• Strong inpatient/post-acute review experience and medical necessity determinations
• Deep knowledge of Medicare Advantage, CMS regulations, and criteria
• Experience with MCG guidelines; InterQual knowledge preferred

🎁 Benefits

• Fully remote position within the United States
• Full-time, Monday–Friday schedule aligned with Pacific Time
• Leadership role influencing quality, coordination, and outcomes
• Opportunity to mentor staff and contribute to management initiatives