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Medical Director – Utilization Management
Bickham Services Unlimited, LLC. Conduct timely utilization reviews and medical necessity determinations for inpatient admissions and continued stays .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in utilization management, including conducting medical necessity determinations and applying regulatory standards. Possesses strong clinical experience in inpatient and post-acute care settings, with a focus on quality improvement and compliance.
Highest-signal resume keywords
Active M.D. Or D.O. LicenseBoard Certification In Medical SpecialtyUtilization Management ExperienceExperience With MCG And InterQual GuidelinesKnowledge Of Medicare Advantage And CMS Criteria
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewMedical Necessity DeterminationClinical EvaluationPeer-To-Peer DiscussionsQuality Improvement InitiativesRegulatory ComplianceAudit ReadinessAccreditation StandardsDocumentation According To CMSPost-Acute Care Services Review
Soft Skills
CollaborationCommunicationProblem-SolvingLeadership
Certifications & Qualifications
ABQAURP CertificationMaster's Degree (MPH, MBA, MHA)
Industry Keywords
Managed CareHealth Plan EnvironmentCommercial BenefitsCoverage RequirementsMember Benefit PlansInpatient CarePost-Acute CareSNFIRFLTACH
About the role
Key responsibilities & impact- 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
Requirements
What you’ll need- Active, unrestricted M.D. or D.O. license in good standing
- Current board certification in an appropriate medical specialty
- At least 5 years of clinical experience, including at least 3 years of experience in utilization management, physician review, or medical leadership within a managed care or health plan environment
- Physician-level utilization management experience supporting Commercial and/or Medicare Advantage populations
- Strong experience with inpatient and post-acute care reviews and medical necessity determinations
- Knowledge of commercial benefits, coverage requirements, and medical policies
- Knowledge of Medicare Advantage and CMS coverage criteria
- Experience applying MCG and/or InterQual guidelines
- Experience conducting peer-to-peer discussions and communicating complex or adverse determinations
- Candidate must reside in or hold applicable licensure for New Jersey
- Preferred: Master's degree such as MPH, MBA, or MHA
- Preferred: ABQAURP certification
- Preferred: Experience with quality improvement, regulatory compliance, accreditation, or delegated oversight
Benefits
Comp & perks- Potential contract extension
- Standard business hours schedule
- Remote work arrangement