Medical Director; Utilization Management

Description:

The Medical Director (Utilization Management) plays a critical role in leading and supporting the clinical integrity of the utilization management function, with a specific focus on inpatient and post-acute care reviews. This physician leader ensures timely and appropriate care determinations for Medicare Advantage members, guided by clinical criteria, CMS regulations, and evidence-based practices.

Reporting to the Chief Medical Officer, this role focuses on evaluating medical necessity and appropriateness of hospital admissions, continued stays, and post-acute services. The Medical Director collaborates with care management teams, providers, and internal stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, and regulatory compliance.

• Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings (e.g., SNF, IRF, LTACH, home health) for Medicare Advantage members
• Assess appropriateness of acute care services using evidence-based guidelines (e.g., MCG, Inter Qual) and CMS criteria
• Serve as the physician reviewer for escalated or complex UM cases requiring medical judgment
• Collaborate with utilization management and care management teams to ensure consistent, clinically appropriate, and cost-effective care
• Participate in peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care
• Identify trends in care utilization and support the development of interventions to reduce unnecessary admissions or extended stays
• Provide input into the development and implementation of medical policy and UM protocols
• Support CMS regulatory compliance, audit preparedness, and delegated oversight for UM functions
• Contribute clinical expertise to quality improvement initiatives related to utilization patterns, readmission reduction, and transitions of care
• Document all reviews and decisions according to NCQA, CMS, and organizational requirements
• Participate in UM committee meetings and represent the health plan in external provider and stakeholder engagements as needed

Quant Dynamics Solutions is consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.