Medical Director (Utilization Management)

HJSRLLC; United States; Remote; USD 180,000 - 240,000; Full time

Job summary

HJ Staffing is seeking a Medical Director of Utilization Management to lead clinical reviews for a Medicare Advantage plan. This 100% remote role reports to the Chief Medical Officer and focuses on evaluating hospital admissions, continued stays, and post-acute services using CMS regulations and MCG/InterQual guidelines.

You will collaborate with care management teams, lead physician discussions, and ensure documentation meets NCQA and CMS standards while driving cost-effective, high-quality

Qualifications

• Licensed MD or DO in good standing in your state of residence.
• Minimum of 5 years of clinical experience.
• At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
• Strong knowledge of Medicare Advantage regulations and CMS criteria.
• Experience with MCG/InterQual guidelines and medical management software.

Responsibilities

• Conduct timely medical necessity determinations for inpatient admissions and post-acute settings.
• Apply CMS criteria and MCG/InterQual guidelines to assess the appropriateness of care.
• Lead peer-to-peer discussions with attending physicians to clarify clinical documentation.
• Serve as primary reviewer for escalated or complex UM cases.
• Collaborate with utilization and care management teams; participate in UM committee meetings.
• Ensure documentation meets NCQA and CMS requirements; support audits.
• Identify utilization trends to reduce unnecessary admissions and extended stays.

Skills

Utilization management

Medical leadership

Clinical data analysis

CMS/Medicare Advantage

MS Office

Education

MD/DO license

ABQAURP certification

MPH/MBA/MHA

Tools

MCG guidelines

InterQual

MS Office

Job description

HJ Staffing is urgently seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. This physician leader will play a critical role in ensuring the clinical integrity of inpatient and post-acute care reviews, evaluating medical necessity to support optimal outcomes and regulatory compliance.

Location: 100% Remote

Schedule: Full-Time, Monday – Friday (Must work PST hours)

Job Description

Reporting to the Chief Medical Officer, the Medical Director focuses on Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members. You will guide timely care determinations using CMS regulations and evidence-based practices (MCG/InterQual) while collaborating with care management teams and external providers.

What You Will Do

• Clinical Review: Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
• Criteria Application: Use evidence-based guidelines (MCG/InterQual) and CMS criteria to assess the appropriateness of acute care services.
• Peer-to-Peer: Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
• Complex Case Management: Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
• Collaboration: Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings.
• Compliance & Documentation: Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight.
• Utilization Trends: Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.

What You Will Bring

• Credentials: Licensed M.D. or D.O. in good standing in your state of residence.
• Clinical Experience: Minimum of 5 years of clinical experience.
• Managed Care Expertise: At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
• Specialized Knowledge: Strong experience in inpatient/post-acute case review and deep knowledge of Medicare Advantage regulations and CMS coverage criteria.
• Technical Skills: Extensive experience with MCG guidelines and advanced proficiency in MS Office and medical management software.
• Education (Preferred): MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).

You Will Be Successful If:

• You are an expert in using data to design and implement clinical programs and population health management.
• You possess strong negotiation skills, particularly in physician-to-physician interactions.
• You thrive in a matrix organization and can mentor staff while making independent, high-stakes decisions.
• You have a meticulous eye for detail and can maintain a reasonable rate of speed in a fast-paced, high-volume environment.
• You are committed to the highest standards of confidentiality and clinical documentation.