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

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Eastern Pennsylvania Physician Alliance (EPPA) is seeking a medical physician for psychiatric inpatient services at facilities located in central and western Pennsylvania. The schedule is PRN for medical H & Ps, consults, and follow-ups. This is a remote position. Qualifications - Board-certified family medicine or internal medicine - Active Pennsylvania medical license - Active DEA Requirements - Medical H & Ps, consults, and follow-ups for inpatient psychiatry patients - Collaborate with physicians, APPs, and support staff Benefits - Competitive compensation rate - Malpractice

• Independently deliver all medical support required for successful delivery of the projects • Actively listen and address client feedback and suggestions regarding medical study-related activities • Provide medical expertise in Proposal Development Teams

• Lead Chamber’s core clinical programs (ToC, GDMT, Complex Care), ensuring adherence to evidence-based protocols and continuous improvement. • Supervise and mentor Nurse Practitioners and Care Coordinators, fostering excellence in patient-centered, protocol-driven care. • Develop and pilot new clinical programs, including emerging pathways • Ensure seamless collaboration with network cardiologists and other providers to align on standards of care and population goals. • Partner with Product, Engineering, and Analytics teams to design and test AI-enabled clinical tools, workflows, and dashboards. • Translate clinical needs into product specifications that streamline care delivery and measurement. • Lead clinical input into product roadmaps and new feature development to enhance patient and provider experience. • Evaluate and operationalize innovations that improve clinical efficiency and engagement. • Define and monitor metrics for outcomes, utilization, and medication adherence across programs. • Lead outcomes reviews and payer discussions focused on performance and impact. • Partner with analytics to identify opportunities for intervention, improvement, and automation. • Establish feedback loops between care teams, technology, and leadership to drive continuous improvement. • Work cross-functionally with Population Health, Operations, and Network teams to translate strategy into execution. • Serve as a clinical voice in payer, provider, and partner meetings to communicate Chamber’s value • Contribute to internal leadership discussions on care design, quality improvement, and program expansion.