Medical Director, Utilization Management (Commercial & MA)

We are seeking a Medical Director of Utilization Management to lead and support the clinical integrity of our utilization management (UM) functions with a primary focus on inpatient and post-acute care reviews.

In this role you will ensure timely consistent and appropriate care determinations for Commercial and Medicare Advantage members. By leveraging evidence-based practices CMS regulations and health plan benefit structures you will evaluate the medical necessity of care participate in peer-to-peer consultations and collaborate with multidisciplinary teams to drive optimal clinical outcomes regulatory compliance and cost efficiency.

Duration: August 10 2026 February 10 2027

Location: Henderson NV (100% Fully Remote Opportunity)

Reporting To: Chief Medical Officer

Start Date: Immediate Need

• Utilization Review & Medical Necessity: Conduct timely medical necessity determinations for inpatient admissions continued stays and post-acute care settings (SNF IRF LTACH Home Health) for Commercial and Medicare Advantage populations.
• Evidence-Based Evaluation: Apply nationally recognized guidelines (MCG InterQual) CMS coverage criteria and health plan policies to ensure appropriate level-of-care determinations.
• Complex Case Escalation: Serve as the lead physician reviewer for complex high-risk or potentially adverse UM cases requiring clinical judgment.
• Peer-to-Peer Engagement: Conduct peer-to-peer discussions with attending and treating physicians to clarify documentation discuss options and align on appropriate care plans.
• Cross-Functional Collaboration: Partner with Care Management and UM teams to identify utilization trends reduce avoidable readmissions/extended stays and streamline care transitions.
• Policy & Quality Support: Offer clinical expertise to support quality improvement initiatives regulatory audit preparedness (CMS/NCQA) policy development and UM committee activities.
• Documentation & Compliance: Maintain precise compliant and timely documentation of all reviews and rationales in accordance with federal state and organizational guidelines.

• Education & Licensure: Active M.D. or D.O. degree with an active unrestricted medical license in good standing (in state of residence).
• Board Certification: Current Board Certification in an appropriate medical specialty.
• Clinical & Leadership Experience: Minimum of 5 years of clinical practice including at least 3 years of direct experience in utilization management physician review or medical leadership within a managed care or health plan setting.
• Population Expertise: Demonstrated physician-level experience supporting Commercial and/or Medicare Advantage lines of business.

• Criteria Proficiency: Advanced expertise with MCG guidelines and strong working knowledge of InterQual and CMS criteria.
• Regulatory Knowledge: Deep understanding of Medicare Advantage regulations Commercial health plan benefit structures and state/federal UM mandates.
• Technical Skills: Experience navigating medical management platforms enterprise applications and Microsoft Office products.
• Communication & Negotiation: Exceptional written and oral communication skills with a proven ability to handle delicate peer-to-peer discussions and articulate complex clinical rationales clearly.
• Analytical Mindset: Strong problem-solving abilities attention to detail and a data-driven approach to identifying utilization trends and quality gaps.

• Masters degree in Public Health Business Administration or Health Administration (MPH MBA or MHA).
• Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).

This is a 100% remote high-impact contract opportunity starting immediately offering you the flexibility of working from home while managing key clinical determinations for a dynamic health plan environment.