Medical Director, Utilization & Care Optimization

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 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.