Medical Director (Utilization Management) (#25-05424)

QUANT DYNAMICS SOLUTIONS; Nevada (IA); On-site; USD 180,000 - 240,000; Full time

Job summary

Quant Dynamics Solutions seeks a Medical Director (Utilization Management) to lead clinical integrity for inpatient and post-acute reviews for Medicare Advantage members. You will guide medical necessity determinations, collaborate with UM and care teams, and ensure compliant, cost-effective care.

Reporting to the Chief Medical Officer, you will document reviews per NCQA/CMS, participate in peer discussions, and contribute to policy development and quality improvement initiatives.

Qualifications

• Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings for Medicare Advantage.
• Assess appropriateness of acute care services using evidence-based guidelines (MCG, InterQual) and CMS criteria.
• Serve as physician reviewer for escalated UM cases requiring medical judgment.
• Collaborate with UM and care management teams to ensure clinically appropriate, cost-effective care.
• Document reviews and decisions according to NCQA, CMS, and organizational requirements.

Responsibilities

• Lead and support clinical integrity of the utilization management function for inpatient and post-acute reviews.
• Participate in peer-to-peer discussions with attending physicians to clarify documentation and care levels.
• Identify trends in utilization and support interventions to reduce unnecessary admissions.
• Contribute clinical expertise to medical policy development and UM protocols.
• Support CMS regulatory compliance, audit readiness, and delegated UM oversight.
• Represent the health plan in UM committee meetings and external engagements as needed.

Skills

Utilization management

Clinical leadership

CMS guidelines knowledge

Evidence-based criteria

Medical policy input

Quality improvement

Regulatory compliance

Clinical documentation

Peer-to-peer discussions

Education

MD/DO

Job description

Description

About the Role

The Medical Director (Utilization Management) plays a critical role in leading and supporting the clinical integrity of the utilization management function, with a specific focus on inpatient and post-acute care reviews. This physician leader ensures timely and appropriate care determinations for Medicare Advantage members, guided by clinical criteria, CMS regulations, and evidence-based practices.

Reporting to the Chief Medical Officer, this role focuses on evaluating medical necessity and appropriateness of hospital admissions, continued stays, and post-acute services. The Medical Director collaborates with care management teams, providers, and internal stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, and regulatory compliance.

Requirements

• Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings (e.g., SNF, IRF, LTACH, home health) for Medicare Advantage members
• Assess appropriateness of acute care services using evidence-based guidelines (e.g., MCG, InterQual) and CMS criteria
• Serve as the physician reviewer for escalated or complex UM cases requiring medical judgment
• Collaborate with utilization management and care management teams to ensure consistent, clinically appropriate, and cost-effective care
• Participate in peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care
• Identify trends in care utilization and support the development of interventions to reduce unnecessary admissions or extended stays
• Provide input into the development and implementation of medical policy and UM protocols
• Support CMS regulatory compliance, audit preparedness, and delegated oversight for UM functions
• Contribute clinical expertise to quality improvement initiatives related to utilization patterns, readmission reduction, and transitions of care
• Document all reviews and decisions according to NCQA, CMS, and organizational requirements
• Participate in UM committee meetings and represent the health plan in external provider and stakeholder engagements as needed

About The Company

Quant Dynamics Solutions is consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.