Medical Director, Utilization Management

Bickham Services Unlimited, LLC; New Jersey; Remote; USD 152,000 - 234,000; Full time

Job summary

Bickham Services Unlimited, LLC is seeking a Medical Director, Utilization Management to lead clinical utilization reviews for inpatient and post-acute care, ensuring medical necessity determinations align with CMS, policies, and evidence-based criteria.

Remote opportunity in New Jersey for a board-certified physician with strong leadership in managed care, responsible for regulatory compliance, quality initiatives, and collaboration with care management teams.

Qualifications

• MD/DO license active in good standing.
• Board-certified in medical specialty.
• 5+ years clinical experience, 3+ in UM or medical leadership within managed care.

Responsibilities

• Lead and support clinical utilization management activities for inpatient and post-acute reviews.
• Review post-acute services (SNF, IRF, LTACH, home health) for medical necessity.
• Apply CMS criteria, medical policies, and evidence-based practices to determinations.

Skills

Clinical leadership

Utilization management

Regulatory knowledge

Education

MD/DO degree

Board certification

Tools

MCG guidelines

InterQual

Job description

Medical Director, Utilization Management

Location: New Jersey - Fully Remote
Work Arrangement: Remote
Job Type: Contract
Contract Length: 6-9 months, with potential for extension
Schedule: Standard business hours; schedule to be determined with the client
Start Date: Immediate / ASAP
Department: Healthcare - Utilization Management (Clinical)
Reports To: Chief Medical Officer
Openings: 1
Pay: Hourly, DOE

About the Position

Bickham Services Unlimited, LLC is seeking a Medical Director, Utilization Management to support a healthcare utilization management program serving Commercial and Medicare Advantage members.

The Medical Director will lead and support clinical utilization management activities, with a primary focus on inpatient and post-acute care reviews. This position is responsible for ensuring timely, consistent, and appropriate medical necessity determinations based on member benefit plans, medical policies, clinical criteria, CMS regulations, and evidence-based practices.

Key Responsibilities

• Conduct timely utilization reviews and medical necessity determinations for inpatient admissions and continued stays.
• Review post-acute care services, including SNF, IRF, LTACH, and home health.
• Evaluate the appropriateness of acute and post-acute services using MCG, InterQual, CMS criteria, commercial medical policies, and member benefit plans.
• Apply applicable regulatory and coverage standards based on the member's line of business.
• Serve as a physician reviewer for escalated, complex, or potentially adverse utilization management cases.
• Participate in peer-to-peer discussions with treating and attending physicians.
• Collaborate with utilization management and care management teams to support consistent and cost-effective care.
• Identify utilization trends and support initiatives designed to reduce avoidable admissions and readmissions.
• Provide clinical input regarding medical policies, clinical guidelines, and utilization management protocols.
• Support regulatory compliance, audit readiness, accreditation, and delegated oversight activities.
• Contribute to quality improvement initiatives involving utilization patterns, readmissions, and care transitions.
• Ensure reviews and determinations are appropriately documented in accordance with CMS, NCQA, and applicable state and federal requirements.
• Participate in utilization management committee meetings and represent the health plan externally when needed.

Minimum Qualifications

• Active, unrestricted M.D. or D.O. license in good standing.
• Current board certification in an appropriate medical specialty.
• At least 5 years of clinical experience, including at least 3 years of experience in utilization management, physician review, or medical leadership within a managed care or health plan environment.
• Physician-level utilization management experience supporting Commercial and/or Medicare Advantage populations.
• Strong experience with inpatient and post-acute care reviews and medical necessity determinations.
• Knowledge of commercial benefits, coverage requirements, and medical policies.
• Knowledge of Medicare Advantage and CMS coverage criteria.
• Experience applying MCG and/or InterQual guidelines.
• Experience conducting peer-to-peer discussions and communicating complex or adverse determinations.
• Candidate must reside in or hold applicable licensure for New Jersey.

Preferred Qualifications

• Master's degree such as MPH, MBA, or MHA.
• ABQAURP certification.
• Experience with quality improvement, regulatory compliance, accreditation, or delegated oversight.