Appworkshub

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description 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. - 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 Qualifications - 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 Requirements - 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) Benefits - 100% Remote | Must work PST hours Preferred - MPH, MBA, or MHA - ABQAURP Certification