Medical Director – Utilization Management

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🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

👻 Ghost score 12%

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HJ Staffing

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Founded 2016

💼 Consulting

📦 Logistics

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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

• Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members • Conduct timely medical necessity determinations for inpatient admissions and post-acute settings, including SNF, IRF, LTACH, and Home Health • Apply MCG/InterQual evidence-based guidelines and CMS criteria to assess acute care appropriateness • 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 • Collaborate with utilization and care management teams to ensure consistent, cost-effective care • Participate in utilization management committee meetings • Document decisions 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 • Report to the Chief Medical Officer

🎯 Requirements

• Licensed M.D. or D.O. in good standing in your 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/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 • Expert use of data to design and implement clinical programs and population health management • Strong negotiation skills, particularly in physician-to-physician interactions • Ability to thrive in a matrix organization and mentor staff • Ability to make independent, high-stakes decisions • Meticulous attention to detail and ability to maintain a reasonable rate of speed in a fast-paced, high-volume environment • Commitment to confidentiality and clinical documentation standards • MPH, MBA, or MHA preferred • Certification by ABQAURP preferred

🏖️ Benefits

• Full-time schedule, Monday–Friday • 100% remote work • Opportunity to join a leading Medicare Advantage Health Plan • Participation in UM committee meetings • Ability to mentor staff and make independent, high-stakes decisions

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