Medical Director, Utilization Management - Inpatient Care

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

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.