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Medical Director – Utilization Management
HJ Staffing. Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management and Medical Leadership, with a strong focus on Medicare Advantage regulations, MCG guidelines, and clinical decision-making. Proven ability to lead peer discussions, mentor staff, and implement data-driven clinical programs.
Highest-signal resume keywords
Licensed M.D. Or D.O.Utilization Management ExperienceMedicare Advantage Regulations KnowledgeMCG Guidelines ExpertiseStrong Negotiation Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ExperienceInpatient Case ReviewMedical Necessity DeterminationData AnalysisPopulation Health Management
Soft Skills
Attention To DetailIndependent Decision-MakingMentoring AbilityCollaboration Skills
Tools & Technologies
MS OfficeMedical Management Software
Certifications & Qualifications
ABQAURP CertificationMPHMBAMHA
Industry Keywords
Medicare AdvantageCMS CriteriaUtilization ManagementClinical Documentation StandardsAudit Preparedness
About the role
Key responsibilities & impact- Evaluate hospital admissions, continued stays, and post-acute services for Medicare Advantage members
- Conduct timely medical necessity determinations for inpatient admissions and post-acute settings, including SNF, IRF, LTACH, and Home Health
- Apply MCG/InterQual evidence-based guidelines and CMS criteria to assess acute care appropriateness
- Lead peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care
- Serve as the primary physician reviewer for escalated or complex utilization management cases
- Collaborate with utilization and care management teams to ensure consistent, cost-effective care
- Participate in utilization management committee meetings
- Document decisions according to NCQA and CMS requirements
- Support audit preparedness and delegated oversight
- Identify utilization trends and support interventions to reduce unnecessary admissions or extended stays
- Report to the Chief Medical Officer
Requirements
What you’ll need- Licensed M.D. or D.O. in good standing in your state of residence
- Minimum of 5 years of clinical experience
- At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting
- Strong experience in inpatient/post-acute case review
- Deep knowledge of Medicare Advantage regulations and CMS coverage criteria
- Extensive experience with MCG guidelines
- Advanced proficiency in MS Office and medical management software
- Expert use of data to design and implement clinical programs and population health management
- Strong negotiation skills, particularly in physician-to-physician interactions
- Ability to thrive in a matrix organization and mentor staff
- Ability to make independent, high-stakes decisions
- Meticulous attention to detail and ability to maintain a reasonable rate of speed in a fast-paced, high-volume environment
- Commitment to confidentiality and clinical documentation standards
- MPH, MBA, or MHA preferred
- Certification by ABQAURP preferred
Benefits
Comp & perks- Full-time schedule, Monday–Friday
- 100% remote work
- Opportunity to join a leading Medicare Advantage Health Plan
- Participation in UM committee meetings
- Ability to mentor staff and make independent, high-stakes decisions