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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 collaborate with healthcare teams and lead complex case reviews while ensuring compliance with NCQA and CMS standards.
Highest-signal resume keywords
Licensed M.D. Or D.O.Utilization Management ExperienceMedicare Advantage Regulations KnowledgeMCG Guidelines ExpertiseInpatient/Post-Acute Case Review
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 ExperienceMedical Necessity DeterminationsData AnalysisClinical Program DesignPopulation Health Management
Soft Skills
Negotiation SkillsMentoring AbilityAttention To DetailIndependent Decision-MakingCollaboration
Tools & Technologies
MS OfficeMedical Management Software
Industry Keywords
Utilization ManagementCMS CriteriaPeer-To-Peer DiscussionsAudit PreparednessClinical Documentation Standards
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 services
- Lead peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care
- Serve as 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
- Use data to design and implement clinical programs and population health management initiatives
- Report to the Chief Medical Officer
Requirements
What you’ll need- Licensed M.D. or D.O. in good standing in the candidate’s 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
- Strong negotiation skills, particularly in physician-to-physician interactions
- Ability to work 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
Benefits
Comp & perks- Full-time Monday–Friday schedule
- 100% remote work