United States onlyWe are looking for an experienced UM Medical Director to lead the clinical integrity of our utilization management function. This physician leader will focus specifically on inpatient and post-acute care reviews, ensuring timely and appropriate care determinations for our Medicare Advantage members.
Reporting to the Chief Medical Officer, you will evaluate medical necessity for hospital admissions, continued stays, and post-acute services (SNF, IRF, LTACH, and Home Health), ensuring all decisions align with CMS regulations and evidence-based practices.
What You Will Do
- Utilization Review: Conduct clinical reviews for inpatient admissions and post-acute settings using evidence-based guidelines (MCG, InterQual) and CMS criteria.
- Complex Case Management: Serve as the primary physician reviewer for escalated or complex cases requiring high-level medical judgment.
- Peer-to-Peer Consultation: Engage in peer-to-peer discussions with attending physicians to clarify clinical documentation and support the appropriate level of care.
- Strategic Collaboration: Partner with care management teams to identify utilization trends and develop interventions to reduce unnecessary admissions or extended stays.
- Compliance & Documentation: Ensure all decisions are documented in strict accordance with NCQA, CMS, and organizational standards.
- Quality Improvement: Contribute expertise to initiatives focused on readmission reduction and transitions of care.
You Will Be Successful If
- Expertise in Criteria: You possess extensive knowledge of MCG guidelines and their application in clinical decision-making.
- Collaborative Mindset: You excel at working within a matrixed organization and can build relationships at all levels.
- Analytical Prowess: You have strong problem-solving skills and the ability to explain complex clinical information clearly.
- Integrity: You maintain the highest standards of confidentiality and attention to detail.
- Tech Savvy: You are comfortable with medical management systems and advanced MS Office products.
What You Will Bring
- Licensure: M.D. or D.O. in good standing in your state of residence.
- Clinical Background: Minimum of 5 years of clinical experience.
- Managed Care Experience: At least 3 years in a Utilization Management or medical leadership role within a health plan setting.
- MA Knowledge: Strong experience with Medicare Advantage case reviews and CMS coverage criteria.
- Preferred: MPH, MBA, or MHA; Certification by the ABQAURP.
