Medical Director – Utilization Management

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HJ Staffing

WebsiteLinkedInAll Job Openings

11 - 50 employees

Founded 2016

💼 Consulting

📦 Logistics

🏗️ Construction

Consulting • Logistics • Construction

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 and post-acute settings, including SNF, IRF, LTACH, and Home Health • Use MCG/InterQual evidence-based guidelines and CMS criteria to assess acute care services • Lead peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care • Serve as the primary physician reviewer for escalated or complex utilization management cases • Partner with utilization and care management teams to ensure consistent, cost-effective care • Participate in utilization management committee meetings • Ensure decisions are documented according to NCQA and CMS requirements • Support audit preparedness and delegated oversight • Identify utilization trends and support interventions to reduce unnecessary admissions or extended stays • Mentor staff and make independent, high-stakes clinical decisions in a matrix organization

🎯 Requirements

• Licensed M.D. or D.O. in good standing in the candidate’s state of residence • Minimum of 5 years of clinical experience • At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting • Strong experience in inpatient and post-acute case review • Deep knowledge of Medicare Advantage regulations and CMS coverage criteria • Extensive experience with MCG guidelines • Advanced proficiency in MS Office and medical management software • MPH, MBA, or MHA preferred • ABQAURP certification preferred • Expertise using data to design and implement clinical programs and population health management • Strong negotiation skills for physician-to-physician interactions • Ability to work in a matrix organization, mentor staff, and make independent high-stakes decisions • Meticulous attention to detail and ability to work at a reasonable speed in a fast-paced, high-volume environment • Commitment to confidentiality and clinical documentation • Must work PST hours