Medical Director, Utilization Management (Commercial & MA)

We are seeking a Medical Director of Utilization Management to lead and support the clinical integrity of our utilization management (UM) functions, with a primary focus on inpatient and post-acute care reviews. In this role, you will ensure timely, consistent, and appropriate care determinations for Commercial and Medicare Advantage members. By leveraging evidence-based practices, CMS regulations, and health plan benefit structures, you will evaluate the medical necessity of care, participate in peer-to-peer consultations, and collaborate with multidisciplinary teams to drive optimal clinical outcomes, regulatory compliance, and cost efficiency. Duration: August 10, 2026 – February 10, 2027 Location: Henderson, NV (100% Fully Remote Opportunity) Reporting To: Chief Medical Officer Start Date: Immediate Need Key Responsibilities Utilization Review & Medical Necessity: Conduct timely medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings (SNF, IRF, LTACH, Home Health) for Commercial and Medicare Advantage populations. Evidence-Based Evaluation: Apply nationally recognized guidelines (MCG, InterQual), CMS coverage criteria, and health plan policies to ensure appropriate level-of-care determinations. Complex Case Escalation: Serve as the lead physician reviewer for complex, high-risk, or potentially adverse UM cases requiring clinical judgment. Peer-to-Peer Engagement: Conduct peer-to-peer discussions with attending and treating physicians to clarify documentation, discuss options, and align on appropriate care plans. Cross-Functional Collaboration: Partner with Care Management and UM teams to identify utilization trends, reduce avoidable readmissions/extended stays, and streamline care transitions. Policy & Quality Support: Offer clinical expertise to support quality improvement initiatives, regulatory audit preparedness (CMS/NCQA), policy development, and UM committee activities. Documentation & Compliance: Maintain precise, compliant, and timely documentation of all reviews and rationales in accordance with federal, state, and organizational guidelines. Must-Have Qualifications Education & Licensure: Active M.D. or D.O. degree with an active, unrestricted medical license in good standing (in state of residence). Board Certification: Current Board Certification in an appropriate medical specialty. Clinical & Leadership Experience: 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. Population Expertise: Demonstrated physician-level experience supporting Commercial and/or Medicare Advantage lines of business. What Will Make You Successful Criteria Proficiency: Advanced expertise with MCG guidelines and strong working knowledge of InterQual and CMS criteria . Regulatory Knowledge: Deep understanding of Medicare Advantage regulations, Commercial health plan benefit structures, and state/federal UM mandates. Technical Skills: Experience navigating medical management platforms, enterprise applications, and Microsoft Office products. Communication & Negotiation: Exceptional written and oral communication skills, with a proven ability to handle delicate peer-to-peer discussions and articulate complex clinical rationales clearly. Analytical Mindset: Strong problem-solving abilities, attention to detail, and a data-driven approach to identifying utilization trends and quality gaps. Preferred Qualifications Master’s degree in Public Health, Business Administration, or Health Administration ( MPH, MBA, or MHA ). Certification by the American Board of Quality Assurance and Utilization Review Physicians ( ABQAURP ). Why Apply? This is a 100% remote, high-impact contract opportunity starting immediately, offering you the flexibility of working from home while managing key clinical determinations for a dynamic health plan environment. Originally posted on Himalayas