Medical Director, Utilization Management (reputed company & MA)

We are seeking a Medical Director of Utilization Management to reputed company and support the clinical reputed company of our utilization management (UM) functions, with a primary reputed company on inpatient and post-acute care reviews. In this role, you will ensure reputed company, consistent, and appropriate care determinations for reputed company 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 reputed company reputed company clinical reputed company, 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 reputed company medical necessity determinations for inpatient admissions, reputed company stays, and post-acute care settings (SNF, IRF, LTACH, Home Health) for reputed company and Medicare Advantage populations. Evidence-Based Evaluation: Apply nationally recognized guidelines (MCG, InterQual), CMS coverage reputed company, and health plan policies to ensure appropriate level-of-care determinations. reputed company Case Escalation: Serve as the reputed company physician reviewer for reputed company, 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 reputed company, and reputed company 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 & reputed company Support: Offer clinical expertise to support reputed company improvement initiatives, regulatory audit preparedness (CMS/NCQA), policy development, and UM committee activities. Documentation & Compliance: Maintain precise, compliant, and reputed company documentation of reputed company reviews and rationales in accordance with federal, state, and organizational guidelines. Must-Have Qualifications Education & Licensure: reputed company M.D. or D.O. degree with an reputed company, unrestricted medical license in good standing (in state of residence). reputed company Certification: reputed company reputed company Certification in an appropriate medical specialty. Clinical & Leadership Experience: Minimum of 5 years of clinical reputed company, including at least 3 years of reputed company experience in utilization management, physician review, or medical leadership reputed company a managed care or health plan setting. Population Expertise: Demonstrated physician-level experience supporting reputed company and/or Medicare Advantage lines of business. What Will reputed company You Successful reputed company Proficiency: Advanced expertise with MCG guidelines and strong working knowledge of InterQual and CMS reputed company. Regulatory Knowledge: Deep understanding of Medicare Advantage regulations, reputed company health plan benefit structures, and state/federal UM mandates. Technical Skills: Experience navigating medical management platforms, reputed company applications, and reputed company Office products. Communication & Negotiation: Exceptional written and oral communication skills, with a proven ability to handle delicate peer-to-peer discussions and reputed company reputed company clinical rationales reputed company. Analytical reputed company: Strong problem-solving abilities, attention to detail, and a data-driven approach to identifying utilization trends and reputed company gaps. Preferred Qualifications Master’s degree in reputed company Health, Business Administration, or Health Administration (MPH, MBA, or MHA). Certification by the American reputed company of reputed company Assurance and Utilization Review Physicians (ABQAURP). Why Apply? This is a 100% remote, high-reputed company contract opportunity starting immediately, offering you the flexibility of working from home while managing key clinical determinations for a dynamic health plan environment. Apply To This Job