Bickham Services Unlimited, LLC

Medical Director

• Conduct timely utilization reviews and medical necessity determinations for inpatient admissions and continued stays
• Review post-acute care services, including SNF, IRF, LTACH, and home health
• Evaluate acute and post-acute services using MCG, InterQual, CMS criteria, commercial medical policies, and member benefit plans
• Apply regulatory and coverage standards based on the member's line of business
• Serve as a physician reviewer for escalated, complex, or potentially adverse utilization management cases
• Participate in peer-to-peer discussions with treating and attending physicians
• Collaborate with utilization management and care management teams to support consistent and cost-effective care
• Identify utilization trends and support initiatives to reduce avoidable admissions and readmissions
• Provide clinical input on medical policies, clinical guidelines, and utilization management protocols
• Support regulatory compliance, audit readiness, accreditation, and delegated oversight activities
• Contribute to quality improvement initiatives involving utilization patterns, readmissions, and care transitions
• Ensure reviews and determinations are documented according to CMS, NCQA, and applicable state and federal requirements
• Participate in utilization management committee meetings and represent the health plan externally when needed

Medical Director – Utilization Management