Medical Director

Hanover; Birmingham (AL); On-site; USD 180,000 - 240,000; Full time

Job summary

Associated Care Ventures, Inc. (ACV) is the Birmingham-based parent company of Simpra Advantage, Inc., an Alabama-domiciled insurer managing SNPS plans and integrated care networks for Alabama Medicaid.

The Medical Director, Utilization Management leads medical necessity determinations, utilization reviews, and appeals, ensuring high-quality, cost-effective care and compliance with CMS, NCQA, state, and accreditation requirements.

Qualifications

• MD or DO degree from accredited medical school is required.
• Current unrestricted Alabama medical license is required.
• Board certification in Internal Medicine, Family Medicine, Geriatrics, or Physical Medicine & Rehabilitation is required.
• Minimum 5 years clinical practice experience.
• Minimum 3 years managed care experience.
• Minimum 2 years utilization management experience.

Responsibilities

• Provide physician oversight of all utilization management activities.
• Perform medical necessity reviews for inpatient, observation, outpatient, SNF, Skill in place, and post-acute services.
• Conduct Level II physician reviews and issue adverse determinations when appropriate.
• Develop and implement inpatient and observation review programs.
• Review inpatient admissions for appropriateness of level of care.
• Participate in regulatory audits and accreditation processes.

Skills

Medicare Advantage regulations

InterQual criteria knowledge

Inpatient utilization management

Analytical skills

Physician communication

Negotiation skills

Matrix organization experience

Education

MD or DO degree from accredited medical school

Job description

Associated Care Ventures, Inc. (ACV) is the Birmingham-based parent company of Simpra Advantage, Inc., an Alabama-domiciled insurance company operating an Institutional Special Needs Plan, a Dual Eligible Special Needs Plan, and an Institutional Equivalent Special Needs Plan. ACV is the parent company of Alabama Select Network, LLC, which is operating an Integrated Care Network for the Alabama Medicaid Agency, to coordinate Medicare and Medicaid services state-wide for eligible individuals receiving long-term services and supports, both living at home and in nursing facilities.

Position Summary

The Medical Director, Utilization Management (UM) serves as the physician leader responsible for medical necessity determinations, utilization review activities, appeals, and clinical oversight of the health plan's medical management programs. This position provides physician leadership for inpatient, observation, post-acute, and outpatient utilization management activities to ensure high-quality, cost-effective, and evidence-based care for members.

The Medical Director collaborates closely with nursing UM staff, care management, network providers, quality teams, and executive leadership to improve clinical outcomes, reduce avoidable utilization, and ensure compliance with CMS, NCQA, state, and accreditation requirements.

This role is particularly responsible for building and overseeing the plan's inpatient and outpatient auth requests and observation review processes for a high-risk Special Needs Plan population.

Essential Duties and Responsibilities

• Provide physician oversight of all utilization management activities.
• Perform medical necessity reviews for inpatient, observation, outpatient, SNF, Skill in place, and post-acute services.
• Conduct Level II physician reviews and issue adverse determinations when appropriate.
• Provide guidance regarding application of:
• CMS regulations
• Interqual Criteria
• National and Local Coverage Determinations
• Develop and implement inpatient and observation review programs.
• Review inpatient admissions for appropriateness of level of care.
• Identify opportunities to:
• Prevent readmissions.
• Partner with hospitals and facilities to optimize transitions of care.
• Conduct peer-to-peer discussions with treating physicians.
• Participate in provider education regarding medical necessity requirements.
• Resolve authorization disputes and escalation cases.
• Serve as physician reviewer for appeals and reconsiderations.
• Support external review preparation.
• Ensure regulatory turnaround times are met.

Clinical Program Development

• Collaborate with care management and quality teams to develop:
• Clinical pathways
• Facility-based management programs

Data Analytics & Performance Improvement

• Review utilization trends and identify opportunities for improvement.
• Analyze:
• Admission rates
• Observation rates
• Readmissions
• Denial rates
• Participate in development of predictive models for high-risk populations.

Regulatory & Accreditation Compliance

• Ensure compliance with:
• CMS Medicare Advantage regulations
• NCQA UM standards
• State regulations
• Delegation oversight requirements.
• Participate in audits and regulatory examinations.

Serve as physician lead or member for

• Utilization Management Committee
• Quality Improvement
• Readmission Reduction
• Clinical Policy

Supervisory Responsibilities

Provides physician leadership and clinical oversight for:

• UM Nurse Managers
• UM Nurses
• Clinical Pharmacists (matrix relationship)

Minimum Qualifications

Education

• MD or DO degree from accredited medical school.

Licensure

• Current unrestricted Alabama medical license.
• Ability to obtain additional state licenses as needed.

Board Certification

Board Certified in one of the following:

• Internal Medicine
• Family Medicine
• Geriatrics
• Physical Medicine & Rehabilitation

Experience

Required:

• Minimum 5 years clinical practice experience.
• Minimum 3 years managed care experience.
• Minimum 2 years utilization management experience.

Preferred:

• ISNP, DSNP, PACE, or long-term care experience.
• Experience managing inpatient and observation programs.
• Experience with high-risk geriatric populations.

Knowledge, Skills & Abilities

• Strong understanding of Medicare Advantage regulations.
• Knowledge of MCG/InterQual criteria.
• Expertise in inpatient utilization management.
• Knowledge of long-term care and post-acute care delivery systems.
• Strong analytical skills and data interpretation.
• Excellent physician communication and negotiation skills.
• Ability to function effectively in a matrix organization.