Medical Director (Utilization Management) (Remote)
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Job Description
We're looking for a Medical Director (Utilization Management) to guide clinical integrity in utilization management, focusing on inpatient and post-acute care reviews for Medicare Advantage members.
What You'll Do:
Conduct utilization reviews and determine medical necessity for admissions and post-acute services.
Apply evidence-based guidelines (MCG, InterQual) and CMS criteria.
Collaborate with providers and UM/care management teams.
Participate in peer-to-peer reviews and UM committee meetings.
Support compliance, audits, and quality improvement initiatives.
What You'll Bring:
Licensed M.D. or D.O. (in good standing).
5+ years clinical experience; 3+ years in UM/medical leadership in managed care.
Strong knowledge of Medicare Advantage regulations and CMS coverage.
Familiarity with MCG/InterQual criteria.
Preferred: MPH, MBA, MHA, or ABQAURP certification.
Automate your job search with Sonara.
Submit 10x as many applications with less effort than one manual application.