HJ Staffing is urgently seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. This physician leader will play a critical role in ensuring the clinical integrity of inpatient and post-acute care reviews, evaluating medical necessity to support optimal outcomes and regulatory compliance.
Location: 100% Remote
Schedule: Full-Time, Monday – Friday (Must work PST hours)
Job Description
Reporting to the Chief Medical Officer, the Medical Director focuses on Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members. You will guide timely care determinations using CMS regulations and evidence-based practices (MCG/InterQual) while collaborating with care management teams and external providers.
What You Will Do
Clinical Review: Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
Criteria Application: Use evidence-based guidelines (MCG/InterQual) and CMS criteria to assess the appropriateness of acute care services.
Peer-to-Peer: Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
Complex Case Management: Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
Collaboration: Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings.
Compliance & Documentation: Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight.
Utilization Trends: Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.
What You Will Bring
Credentials: Licensed M.D. or D.O. in good standing in your state of residence.
Clinical Experience: Minimum of 5 years of clinical experience.
Managed Care Expertise: At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
Specialized Knowledge: Strong experience in inpatient/post-acute case review and deep knowledge of Medicare Advantage regulations and CMS coverage criteria.
Technical Skills: Extensive experience with MCG guidelines and advanced proficiency in MS Office and medical management software.
Education (Preferred): MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
You Will Be Successful If:
You are an expert in using data to design and implement clinical programs and population health management.
You possess strong negotiation skills, particularly in physician-to-physician interactions.
You thrive in a matrix organization and can mentor staff while making independent, high-stakes decisions.
You have a meticulous eye for detail and can maintain a reasonable rate of speed in a fast-paced, high-volume environment.
You are committed to the highest standards of confidentiality and clinical documentation.
HJ Staffing is a staffing and recruitment firm specializing in healthcare placements, particularly for physician and clinical leadership positions. The company partners with leading healthcare organizations, including Medicare Advantage Health Plans, to identify and place qualified medical professionals in critical roles. They focus on connecting experienced physicians and healthcare leaders with organizations that need expertise in specialized areas such as utilization management, care coordination, and managed care operations.
