Senior Utilization Review Medical Director

The Senior Medical Director (Senior MD) serves as the clinical and strategic leader for Integra’s Utilization Management (UM) and Credentialing programs. This is a full-time, 40+ hour per week leadership role that must be the physician’s primary professional responsibility, requiring consistent availability standard business hours, with additional availability as operational needs require.

The Senior MD provides clinical oversight to the Utilization Review Medical Director(s), ensures consistent application of criteria, leads medical policy development, maintains compliance with NCQA and regulatory requirements, and serves as the primary clinical contact for contracted health plan partners. This position is responsible for driving strategy, ensuring quality and inter-rater reliability, overseeing audit readiness, and chairing Integra’s Utilization Management Committee and Credentialing Committee.

This role is ideal for a physician leader who excels in clinical operations, regulatory compliance, medical policy, cross‑functional collaboration, and representing Integra’s clinical position to internal and external stakeholders.

The Senior Utilization Review Medical Director’s responsibilities include but are not limited to:

• Provide day‑to‑day clinical leadership and oversight to the Utilization Review Medical Director(s) and clinical UM team.
• Ensure consistent, accurate, and compliant application of criteria (LCDs, state Medicaid manuals, Inter Qual, internal policies, health plan guidelines, and evidence‑based standards).
• Oversee complex clinical escalations, case consultations, and final determinations requiring senior medical judgment.
• Maintain and enforce medical review quality standards, including accuracy, documentation integrity, and compliance with NCQA UM requirements.

• Lead the development, maintenance, and revision of clinical criteria and medical policies, including DMEPOS‑specific guidance.
• Ensure policies reflect current evidence, regulatory updates, clinical best practices, and contract‑specific requirements.
• Partner with health plan medical leadership to align policies, resolve discrepancies, and maintain contractual compliance.
• Serve as the final approver for Integra medical policies and clinical UM guidance documents.

• Serve as the primary clinical contact for contracted health plan medical directors, CMOs, and clinical leadership.
• Lead clinical discussions, resolve escalations, align on criteria interpretations, and represent Integra in clinical presentations and governance meetings.
• Participate in health plan audits, accreditation reviews, and regulatory surveys as the clinical lead.
• Support contracting and implementation teams with clinical expertise during new implementations and renewals.

• Chair the Utilization Management Committee, ensuring compliance with regulatory and NCQA requirements, timely presentation of reports, and documentation accuracy.
• Chair the Credentialing Committee, ensuring appropriate clinical oversight of credentialing decisions, quality concerns, and adverse findings.
• Oversee preparation of committee packets, agendas, minutes, and regulatory documentation.
• Ensure decisions are evidence‑based, impartial, and compliant with NCQA CR standards.

• Provide clinical leadership for NCQA UM and Credentialing standards, ensuring continuous readiness.
• Support and guide internal audits, inter‑rater reliability programs, and clinical quality monitoring.
• Serve as the clinical reviewer for audit findings and contribute to corrective action plan development.
• Ensure adherence to CMS, Medicaid, state DOH, and health plan clinical documentation standards.
• Monitor clinical trends, quality signals, and provider behavior patterns; recommend improvement strategies.

• Collaborate with the SVP of Operations, UM Director, Credentialing leadership, and other internal teams to drive clinical strategy and operational improvement.
• Identify emerging clinical, regulatory, and DMEPOS industry…