Medical Director – Utilization Management

Appworkshub

1d • Remote

About The Position

We’re looking for an experienced Medical Director (Utilization Management) to help lead clinical integrity and medical necessity decision-making across inpatient and post-acute care services for Medicare Advantage members.
Reporting directly to the Chief Medical Officer, this physician leader will play a key role in ensuring appropriate, evidence-based, and compliant care decisions that support quality outcomes, cost efficiency, and regulatory excellence.

Requirements

• Deep expertise using MCG guidelines in clinical decision-making
• Strong background in inpatient and post-acute utilization review
• Experience working in managed care or health plan environments
• Excellent analytical, documentation, and negotiation skills
• Strong physician-to-physician communication abilities
• Collaborative mindset and comfort working in matrix organizations
• High attention to detail and commitment to confidentiality and compliance
• MD or DO, licensed and in good standing
• 5+ years of clinical experience, including 3+ years in UM or medical leadership
• Strong knowledge of Medicare Advantage regulations & CMS coverage criteria
• Experience with MCG or InterQual
• Advanced computer skills (MS Office, medical management systems)

Nice To Haves

• MPH, MBA, or MHA
• ABQAURP Certification

Responsibilities

• Conduct medical necessity reviews for inpatient admissions, continued stays, and post-acute care (SNF, IRF, LTACH, Home Health)
• Apply MCG / InterQual guidelines and CMS criteria to utilization decisions
• Serve as physician reviewer for complex and escalated UM cases
• Participate in peer-to-peer discussions with attending physicians
• Partner with UM and Care Management teams to ensure consistent, cost-effective care
• Support CMS compliance, NCQA standards, audits, and delegated oversight
• Identify utilization trends and contribute to quality improvement initiatives
• Assist in developing medical policies and UM protocols
• Maintain accurate clinical documentation per regulatory standards

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree