Medical Director, Utilization Management

Medical Director Utilization Management

Location: New Jersey Fully Remote
Work Arrangement: Remote
Job Type: Contract
Contract Length: 69 months with potential for extension
Schedule: Standard business hours; schedule to be determined with the client
Start Date: Immediate / ASAP
Department: Healthcare Utilization Management (Clinical)
Reports To: Chief Medical Officer
Openings: 1
Pay: Hourly DOE

About the Position

Bickham Services Unlimited LLC is seeking a Medical Director Utilization Management to support a healthcare utilization management program serving Commercial and Medicare Advantage members.

The Medical Director will lead and support clinical utilization management activities with a primary focus on inpatient and post-acute care reviews. This position is responsible for ensuring timely consistent and appropriate medical necessity determinations based on member benefit plans medical policies clinical criteria CMS regulations and evidence-based practices.

Key Responsibilities

• Conduct timely utilization reviews and medical necessity determinations for inpatient admissions and continued stays.
• Review post-acute care services including SNF IRF LTACH and home health.
• Evaluate the appropriateness of acute and post-acute services using MCG InterQual CMS criteria commercial medical policies and member benefit plans.
• Apply applicable regulatory and coverage standards based on the members line of business.
• Serve as a physician reviewer for escalated complex or potentially adverse utilization management cases.
• Participate in peer-to-peer discussions with treating and attending physicians.
• Collaborate with utilization management and care management teams to support consistent and cost-effective care.
• Identify utilization trends and support initiatives designed to reduce avoidable admissions and readmissions.
• Provide clinical input regarding medical policies clinical guidelines and utilization management protocols.
• Support regulatory compliance audit readiness accreditation and delegated oversight activities.
• Contribute to quality improvement initiatives involving utilization patterns readmissions and care transitions.
• Ensure reviews and determinations are appropriately documented in accordance with CMS NCQA and applicable state and federal requirements.
• Participate in utilization management committee meetings and represent the health plan externally when needed.
  

Minimum Qualifications

• Active unrestricted M.D. or D.O. license in good standing.
• Current board certification in an appropriate medical specialty.
• At least 5 years of clinical experience including at least 3 years of experience in utilization management physician review or medical leadership within a managed care or health plan environment.
• Physician-level utilization management experience supporting Commercial and/or Medicare Advantage populations.
• Strong experience with inpatient and post-acute care reviews and medical necessity determinations.
• Knowledge of commercial benefits coverage requirements and medical policies.
• Knowledge of Medicare Advantage and CMS coverage criteria.
• Experience applying MCG and/or InterQual guidelines.
• Experience conducting peer-to-peer discussions and communicating complex or adverse determinations.
• Candidate must reside in or hold applicable licensure for New Jersey.
  

Preferred Qualifications

• Masters degree such as MPH MBA or MHA.
• ABQAURP certification.
• Experience with quality improvement regulatory compliance accreditation or delegated oversight.
  

Required Experience:

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