Medical Director, Utilization Management-Remote
Core
Lead clinical reviews for medical necessity, treatment appropriateness, and compliance for inpatient, outpatient, and skilled facility services while optimizing utilization and ensuring quality of care.
Role type
Senior IC Medical Director / Physician Advisor (Utilization Management)
Builds
Utilization management protocols, auto-approvals, and clinical review processes for institutional and outpatient services
Domain
Healthcare / Utilization Management / Medicare/CMS Compliance
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical care management, quality management, utilization management, case management, medical staff governance, Medicare/CMS guideline compliance, claim denial process management, interdisciplinary team collaboration, protocol development, interrater reliability testing, medical quality oversight, provider education, clinical outcomes analysis
Preferred skills
Physician Advisor experience, internal medicine residency, subspecialty fellowship
Technologies
Web-based Portal, CMS guidelines, Milliman guidelines, NCD/LCD frameworks
Responsibilities
Conduct second-level clinical reviews for medical necessity and treatment appropriateness; classify levels of care and review continued stays; act as liaison between medical staff, utilization review, and third-party payers; review claim denial processes including appeals and grievances; monitor over- and underutilization of services; develop utilization management protocols; conduct interrater reliability testing; chair Medical Quality Committee; collaborate with Quality Director and Provider Relations to educate physicians on UM processes
Seniority
Senior, hands-on IC with supervisory responsibilities