Medical Director Utilization Management
Core
Physician reviewing clinical information to determine medical appropriateness of services using evidence-based guidelines.
Role type
Senior Utilization Management Physician (Internal Medicine)
Builds
Clinical decision guidelines and evidence-based literature for payer-provider decision-making
Domain
Healthcare / Utilization Management / Internal Medicine
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Internal Medicine clinical practice, evidence-based literature review, medical necessity determination, peer-to-peer clinical discussions, documentation of clinical decisions, managed care regulatory understanding
Preferred skills
Managed care utilization review experience, membership in national/regional specialty societies, licensure in AZ/GA/MS/NC/ND/OK/OR/TX
Technologies
Cohere workflow tools, medical society guidelines
Responsibilities
Review clinical information to determine medical appropriateness of services, Provide timely medical reviews meeting quality and timeliness parameters, Conduct peer-to-peer discussions with treating providers to clarify clinical information and explain review outcomes, Document all communication and decision-making in workflow tools, Support clinical content team in reviewing clinical decision guidelines and evidence-based literature, Support projects for building team's clinical expertise and efficiency
Seniority
Senior, hands-on IC