Utilization Management Medical Director, Medicare Advantage

Appworkshub; United States; Remote; USD 150,000 - 210,000; Full time

Job summary

Appworkshub is seeking an experienced Medical Director (Utilization Management) to lead clinical integrity and medical necessity decisions for Medicare Advantage members across inpatient and post-acute care. Reporting to the Chief Medical Officer, this physician leader ensures evidence-based, compliant care that balances quality outcomes with cost efficiency.

The role requires MD/DO, 5+ years in clinical practice with 3+ years in UM or leadership; strong knowledge of Medicare Advantage, CMS

Qualifications

• MD or DO licensed in good standing.
• At least 5+ years of clinical experience with 3+ years in UM or medical leadership.
• Strong knowledge of Medicare Advantage regulations and CMS coverage criteria.
• Experience with MCG or InterQual guidelines.
• Advanced computer skills with MS Office and medical management systems.

Responsibilities

• Conduct medical necessity reviews for inpatient admissions, continued stays, and post-acute care.
• Apply MCG / InterQual guidelines and CMS criteria to utilization decisions.
• Serve as physician reviewer for complex and escalated UM cases.
• Participate in peer-to-peer discussions with attending physicians.
• Partner with UM and Care Management teams to ensure consistent, cost-effective care.
• Support CMS compliance, NCQA standards, audits, and delegated oversight.
• Identify utilization trends and contribute to quality improvement initiatives.
• Assist in developing medical policies and UM protocols.
• Maintain accurate clinical documentation per regulatory standards.
• Deep expertise using MCG guidelines in clinical decision-making.
• Strong background in inpatient and post-acute utilization review.
• Experience working in managed care or health plan environments.
• Excellent analytical, documentation, and negotiation skills.
• Collaborative mindset and comfort working in matrix organizations.
• High attention to detail and commitment to confidentiality and compliance.

Skills

Medical leadership

Utilization management

CMS criteria

MCG/InterQual

Inpatient utilization review

Analytical skills

Documentation skills

Negotiation skills

Education

MD/DO

Tools

MS Office

Medical management systems

Job description

Appworkshub is seeking an experienced Medical Director (Utilization Management) to lead clinical integrity and medical necessity decisions for Medicare Advantage members across inpatient and post-acute care. Reporting to the Chief Medical Officer, this physician leader ensures evidence-based, compliant care that balances quality outcomes with cost efficiency.

The role requires MD/DO, 5+ years in clinical practice with 3+ years in UM or leadership; strong knowledge of Medicare Advantage, CMS