Now Hiring: Medical Director – Utilization Management
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.
What You'll Do
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
You'll Be Successful If You Have
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
What You Bring
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)
Preferred
MPH, MBA, or MHA
ABQAURP Certification
Now Hiring: Medical Director – Utilization Management
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.
What You'll Do
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
You'll Be Successful If You Have
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
What You Bring
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)
Preferred
MPH, MBA, or MHA
ABQAURP Certification
What You'll Do
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
