Medical Director, Utilization Management
Core
Evaluate outpatient referrals and inpatient direct admissions for medical necessity and appropriateness using Medicare policies and internal guidelines.
Role type
Senior Medical Director, Utilization Management
Builds
Utilization Management authorization processes and clinical guidelines
Domain
Healthcare / Medicare Advantage / Utilization Management
Required skills
Medical licensure, Board Certification, Medicare Advantage experience, Utilization Management review experience, Clinical judgment, Policy interpretation, Peer-to-peer negotiation, Mentoring
Preferred skills
Data-driven decision making, Process improvement, Technology adoption
Technologies
Clover Assistant, Milliman Care Criteria
Responsibilities
Review UM authorization requests for medical necessity, Perform peer-to-peer discussions with providers, Mentor UM nurses, Support quality improvement initiatives, Develop clinical guidelines, Maintain medical credentials
Seniority
Senior, hands-on IC