Remote Medical Director of Utilization Management (PST)

HJSRLLC; United States; Remote; USD 180.000 - 240.000; Vollzeit

Zusammenfassung

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

Qualifikationen

• 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.

Aufgaben

• 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.

Kenntnisse

Utilization management

Medical leadership

Clinical data analysis

CMS/Medicare Advantage

MS Office

Ausbildung

MD/DO license

ABQAURP certification

MPH/MBA/MHA

Tools

MCG guidelines

InterQual

MS Office

Jobbeschreibung

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