Utilization Management Physician Medical Director
Core
Provide physician-level clinical leadership for prior authorization, concurrent review, and appeals programs, serving as the clinical authority for complex medical necessity determinations.
Role type
Senior Utilization Management Physician Medical Director
Builds
Timely, clinically sound, and cost-effective utilization management determinations for a nonprofit health organization serving older adults.
Domain
Healthcare / Utilization Management / Medicare Advantage
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical necessity review, peer-to-peer clinical discussions, regulatory compliance (CMS/NCQA/URAC), program strategy, policy development, quality oversight, provider education, workforce planning, audit support, fraud/waste/abuse identification, clinical mentorship
Preferred skills
Medical Director experience, subspecialty board certification, appeals/grievances expertise, population health knowledge, advanced analytical skills, business insight
Technologies
UM/clinical workflow platforms, electronic health records
Responsibilities
Perform physician-level medical necessity reviews for prior authorization, concurrent, and retrospective cases; conduct peer-to-peer discussions with treating providers; serve as reviewer for first-level appeals and ALJ hearings; partner with leadership to set clinical review policy and criteria; provide clinical guidance and mentorship to RN reviewers; ensure compliance with accreditation standards and regulatory requirements; identify and remediate patterns of inappropriate utilization; communicate determinations and policies to network providers.
Seniority
Senior, hands-on IC with leadership responsibilities