Medical Director, Utilization Management & Care Optimization

Quantdynamicss; Nevada (IA); Hybrid; USD 180,000 - 260,000; Full time

Job summary

Quant Dynamics Solutions seeks a Medical Director (Utilization Management) to lead clinical integrity for Medicare Advantage UM, overseeing inpatient and post-acute reviews and ensuring timely, evidence-based determinations. You will collaborate with care management, providers, and internal stakeholders to align care with clinical and regulatory standards.

The role requires leadership in peer-to-peer discussions, policy development, and compliance with NCQA/CMS while contributing to quality

Responsibilities

• Conduct timely utilization review and medical necessity determinations for inpatient admissions and post-acute care for Medicare Advantage members
• Assess appropriateness of acute care using evidence-based guidelines and CMS criteria
• Serve as physician reviewer for escalated or complex UM cases
• Collaborate with UM and care management teams to ensure cost-effective care
• Participate in peer-to-peer discussions to clarify clinical documentation and care levels
• Identify trends in utilization and support interventions to reduce unnecessary admissions
• Provide input into medical policy and UM protocol development
• Support CMS regulatory compliance, audit preparedness, and delegated UM oversight
• Contribute clinical expertise to quality improvement related to utilization and readmission reduction
• Document all reviews and decisions according to NCQA, CMS, and organizational requirements
• Participate in UM committee meetings and external provider engagements as needed
• Represent the health plan in relevant stakeholder meetings to ensure alignment
• Mentor junior clinicians on UM processes

Job description

Quant Dynamics Solutions seeks a Medical Director (Utilization Management) to lead clinical integrity for Medicare Advantage UM, overseeing inpatient and post-acute reviews and ensuring timely, evidence-based determinations. You will collaborate with care management, providers, and internal stakeholders to align care with clinical and regulatory standards.

The role requires leadership in peer-to-peer discussions, policy development, and compliance with NCQA/CMS while contributing to quality