Medical Director, Utilization Management – Commercial & MA

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🎰 Nevada – Remote

🎰 Nevada – Remote

⏳ Contract/Temporary

🔴 Lead

👨‍⚕️ Medical Director

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Bickham Services Unlimited, LLC

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 2017

🏗️ Construction

💼 Consulting

📦 Logistics

Construction • Consulting • Logistics

Bickham Services Unlimited, LLC is a staffing and recruiting firm that provides temporary, temp-to-hire, direct-hire, and contract placements for government, commercial, and private-sector clients. The company specializes in sourcing in-demand professionals across construction, industrial, information technology, administrative, and support roles, and also offers subcontracting and project support services. Bickham Services highlights experience placing talent from entry-level to executive roles, holds multiple minority- and small-business certifications for government contracting, and operates from Houston, Texas.

📋 Description

• Conduct timely utilization reviews and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings, including SNF, IRF, LTACH, and home health, for Commercial and Medicare Advantage members. • Assess the appropriateness of acute and post-acute services using evidence-based guidelines, including MCG and InterQual, as well as applicable CMS criteria, Commercial medical policies, coverage guidelines, and member benefit plans. • Apply the appropriate regulatory and coverage standards based on the member’s line of business. • Serve as the physician reviewer for escalated, complex, or potentially adverse utilization management cases requiring medical judgment. • Collaborate with utilization management and care management teams to promote consistent, clinically appropriate, and cost-effective care. • Participate in peer-to-peer discussions with treating and attending physicians to clarify clinical documentation and support appropriate levels of care. • Identify trends in care utilization and support interventions designed to reduce avoidable admissions, readmissions, extended stays, and unnecessary healthcare expenditures. • Provide clinical input into the development, interpretation, and implementation of medical policies, clinical guidelines, and utilization management protocols. • Support regulatory compliance, audit preparedness, accreditation requirements, and delegated oversight for Commercial and Medicare Advantage utilization management functions. • Contribute clinical expertise to quality improvement initiatives involving utilization patterns, readmission reduction, care transitions, and member outcomes. • Document all reviews, determinations, and clinical rationales in accordance with CMS, NCQA, applicable state and federal requirements, and organizational policies. • Participate in utilization management committee meetings and represent the health plan in provider, regulatory, and external stakeholder engagements as needed.

🎯 Requirements

• Utilization management experience supporting Commercial and/or Medicare Advantage populations. • Minimum of five years of clinical experience, including at least three years in utilization management, physician review, or medical leadership within a managed care or health plan setting. • An M.D. or D.O. degree with an active, unrestricted medical license in good standing in the state of residence. • Current board certification in an appropriate medical specialty. • Strong experience conducting inpatient and post-acute case reviews and determining the medical necessity and appropriateness of acute and post-acute services. • Knowledge of Commercial health plan benefits, coverage guidelines, medical policies, and applicable state and federal requirements. • Knowledge of Medicare Advantage regulations and CMS coverage criteria. • Experience applying evidence-based clinical guidelines such as MCG or InterQual. • Experience conducting peer-to-peer discussions and communicating adverse or complex clinical determinations.

🏖️ Benefits

• Fully remote opportunity • Immediate start