We are seeking aMedical 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 of5 years of clinical practice, including at least3 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 supportingCommercial and/or Medicare Advantage lines of business.

What Will Make You Successful

Criteria Proficiency: Advanced expertise withMCG guidelines and strong working knowledge ofInterQual andCMS 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 a100% 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.

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