Utilization Review Medical Director (Contract)

Integra Partners; Northern (KY); Hybrid; USD 176,000 - 237,000; Full time

Benefits offered by this job

Competitive compensation

401(k) with company match

Medical, Vision, and Dental benefits

PTO and sick time

Parental leave

Bonuses

Job summary

Integra Partners seeks an experienced Utilization Review Medical Director to lead clinical reviews of DMEPOS requests within a remote UM environment. You will ensure decisions meet Medicare/Medicaid guidelines and internal policies while maintaining timely throughput and documented rationale.

Qualifications include MD/DO with board certification (IM/FM/PM&R), and proven UM experience. Strong communication, audit support, and familiarity with NCQA standards are required for this role.

Qualifications

• MD/DO required with board certification in IM, FM, or PM&R.
• Eligible for Medicare/Medicaid participation; no sanctions.
• Experience with utilization management or clinical reviews is essential.
• Excellent documentation and communication skills are required.
• Ability to work in a high-volume, queue-driven workflow and adhere to timelines.

Responsibilities

• Conduct timely clinical reviews of DMEPOS authorization requests using applicable criteria (LCDs, Medicaid manuals, InterQual, MCG, internal policies).
• Maintain real-time throughput in line with productivity standards.
• Evaluate documentation and render determinations with clear rationale.
• Review escalated cases and consult with external reviewers when needed.
• Engage in Peer-to-Peer discussions and document decisions per SOPs and regulatory standards.
• Support audits and NCQA accreditation activities as required.

Skills

Utilization management experience

Clinical documentation

Strong written and verbal沟通

Education

MD or DO degree

Board certification in Internal Medicine or Family Medicine or Physical Medicine & Rehabilitation

Tools

Electronic UM systems

NCQA UM accreditation standards

DMEPOS reviews

Job description

The Utilization Review Medical Director is responsible for conducting clinical reviews of Durable Medical Equipment (DME) and related requests to support Integra's Utilization Management (UM) operations. Role functions within a structured, high-volume authorization review queue and requires adherence to workflow timelines, clinical accuracy standards, and productivity expectations. The Medical Director ensures determinations are made in accordance with Medicare and Medicaid guidelines, health plan-specific criteria, internal policies, and regulatory requirements. This role is best suited for physicians who thrive in a process-driven environment and are committed to consistency, compliance, and evidence-based decision making.

The Utilization Review Medical Director’s responsibilities include but are not limited to:

• Conduct timely clinical reviews of DMEPOS authorization requests using applicable criteria, including LCDs, Medicaid Manuals, InterQual, MCG, internal medical policies, and health plan requirements.
• Function within a real-time review queue and maintain continuous case throughput in alignment with organizational turnaround and productivity standards.
• Evaluate clinical documentation, identify missing elements, and render determinations supported by clear clinical rationale.
• Review cases escalated by UM staff and/or UM Leadership when criteria do not apply to the enrollee’s unique clinical situation or when clinical judgment is required.
• When appropriate, consult with external board-certified reviewers, engage with ordering practitioners, or conduct additional clinical dialogue prior to rendering a determination.
• Participate in Peer-to-Peer (P2P) discussions, including maintaining availability for scheduled appointment times.
• Document all clinical decisions clearly, concisely, and consistently in accordance with internal SOPs, NCQA standards, and regulatory expectations.
• Maintain inter-rater reliability and participate in periodic calibration reviews to support consistency across the UM program.
• Serve as a clinical resource for UM team, providing guidance on clinical interpretation, criteria application, and complex case review.
• Support internal and external audit activities as needed, including NCQA accreditation, health plan audits, and state Medicaid reviews.
• Notify leadership of observed trends, potential quality concerns, or opportunities to strengthen criteria alignment or operational workflows.
• Maintain up-to-date knowledge of Medicare, Medicaid, DMEPOS policies, clinical standards of care, and regulatory updates relevant to UM.

Requirements:

• MD or DO degree
• Board certification in Internal Medicine, Family Medicine, or Physical Medicine & Rehabilitation
• Eligible for participation in Medicare, Medicaid, and other federally funded programs; no current or past OIG or state sanctions
• Experience performing utilization management or clinical review activities
• Strong written and verbal communication skills with emphasis on documentation accuracy
• Ability to work effectively in a high-volume, queue-based workflow with daily review expectations
• Familiarity with electronic UM systems and authorization platforms
• Experience with DMEPOS reviews
• Experience with NCQA UM accreditation standards
• Prior UM experience for MLTC, Medicaid, or Medicare Advantage plans

Working Conditions and Additional Expectations:

• Remote role requiring consistent availability during standard business hours and responsiveness to daily assignments.
• Case volume and mix vary; continuous throughput and timely review completion are required.
• Must maintain a quiet, secure, and compliant environment for reviewing PHI and participating in P2P calls.
• Secondary employment or consulting arrangements are permitted only if they do not interfere with the full-time expectations and require disclosure/approval.
• Daily accountability measures, productivity monitoring, and adherence to all UM workflows are required.

Salary: $150.00/Hourly

Benefits Offered

• Competitive compensation and annual bonus program
• 401(k) retirement program with company match
• Company-paid life insurance
• Company-paid short term disability coverage (location restrictions may apply)
• Medical, Vision, and Dental benefits
• Paid Time Off (PTO)
• Paid Parental Leave
• Sick Time
• Paid company holidays and floating holidays
• Quarterly company-sponsored events
• Health and wellness programs
• Career development opportunities

Remote Opportunities

We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, Nevada, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington.

Our Story

Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits.

With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We're looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.

Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don't hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.