Medical Director, Utilization Management – Commercial & MA

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🔥 32 minutes ago

🎰 Nevada – Remote

🎰 Nevada – Remote

⏳ Contract/Temporary

🔴 Lead

👨‍⚕️ Medical Director

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HJ Staffing

WebsiteLinkedInAll Job Openings

11 - 50 employees

Founded 2016

🤝 B2B

🎯 Recruiter

👥 HR Tech

B2B • Recruitment • HR Tech

HJ Staffing is a premier staffing agency dedicated to providing tailored workforce solutions for businesses across various industries. With a focus on delivering exceptional human resources support, HJ Staffing connects leading companies with outstanding talent through temporary staffing, direct placement, and human resource consulting. The company serves clients in multiple states including Texas, Louisiana, Delaware, and California, asserting its commitment to a personalized approach and superior customer service in every client relationship.

📋 Description

• Conduct timely medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings for Commercial and Medicare Advantage populations • Apply nationally recognized guidelines to ensure appropriate level-of-care determinations • Serve as the lead physician reviewer for complex, high-risk, or potentially adverse UM cases requiring clinical judgment • Conduct peer-to-peer discussions with attending and treating physicians to clarify documentation, discuss options, and align on appropriate care plans • Partner with Care Management and UM teams to identify utilization trends, reduce avoidable readmissions/extended stays, and streamline care transitions • Offer clinical expertise to support quality improvement initiatives, regulatory audit preparedness, policy development, and UM committee activities • Maintain precise, compliant, and timely documentation of all reviews and rationales in accordance with federal, state, and organizational guidelines.

🎯 Requirements

• Active M.D. or D.O. degree with an active, unrestricted medical license in good standing (in state of residence) • Current Board Certification in an appropriate medical specialty • 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 • Demonstrated physician-level experience supporting Commercial and/or Medicare Advantage lines of business • Advanced expertise with MCG guidelines and strong working knowledge of InterQual and CMS criteria • Deep understanding of Medicare Advantage regulations, Commercial health plan benefit structures, and state/federal UM mandates • Experience navigating medical management platforms, enterprise applications, and Microsoft Office products • Exceptional written and oral communication skills • Strong problem-solving abilities, attention to detail, and a data-driven approach to identifying utilization trends and quality gaps.

🏖️ Benefits

• 100% remote work • High-impact contract opportunity • Immediate start