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Role Description

We 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

• Conduct clinical reviews for inpatient admissions and post-acute settings using evidence-based guidelines (MCG, InterQual) and CMS criteria.
• Serve as the primary physician reviewer for escalated or complex cases requiring high-level medical judgment.
• Engage in peer-to-peer discussions with attending physicians to clarify clinical documentation and support the appropriate level of care.
• Partner with care management teams to identify utilization trends and develop interventions to reduce unnecessary admissions or extended stays.
• Ensure all decisions are documented in strict accordance with NCQA, CMS, and organizational standards.
• Contribute expertise to initiatives focused on readmission reduction and transitions of care.

Qualifications

• M.D. or D.O. in good standing in your state of residence.
• Minimum of 5 years of clinical experience.
• At least 3 years in a Utilization Management or medical leadership role within a health plan setting.
• Strong experience with Medicare Advantage case reviews and CMS coverage criteria.

Requirements

• Extensive knowledge of MCG guidelines and their application in clinical decision-making.
• Ability to work within a matrixed organization and build relationships at all levels.
• Strong problem-solving skills and the ability to explain complex clinical information clearly.
• Maintain the highest standards of confidentiality and attention to detail.
• Comfortable with medical management systems and advanced MS Office products.

Benefits

• MPH, MBA, or MHA preferred.
• Certification by the ABQAURP preferred.