Remote Medical Director of Utilization Management

About the Role

HJ Staffing is seeking a Remote Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. In this pivotal role, you will ensure the clinical integrity of inpatient and post-acute care reviews, evaluating medical necessity to support optimal outcomes and regulatory compliance. This is an exciting opportunity to lead in a critical healthcare role while working in a 100% remote environment.

What You'll Do

• Conduct timely medical necessity determinations for inpatient admissions and post-acute settings.
• Utilize evidence-based guidelines and CMS criteria to assess the appropriateness of acute care services.
• Lead discussions with attending physicians to clarify clinical documentation.
• Serve as the primary physician reviewer for escalated or complex UM cases.
• Partner with utilization and care management teams to ensure consistent care.
• Document all decisions according to NCQA and CMS requirements.
• Identify patterns in care to support interventions reducing unnecessary admissions.

Requirements

• Licensed M.D. or D.O. in good standing.
• Minimum of 5 years of clinical experience.
• At least 3 years in a utilization management or medical leadership role.
• Strong experience in inpatient/post-acute case review.
• Extensive experience with MCG guidelines and proficiency in MS Office.
• Preferred: MPH, MBA, MHA; Certification by ABQAURP.

Nice to Have

• Experience in telehealth or remote healthcare services.
• Familiarity with healthcare regulations and compliance.
• Strong communication and interpersonal skills.

What We Offer

• Opportunity to lead in a critical healthcare role.
• Work in a 100% remote environment.
• Collaborate with healthcare professionals across the country.
• Engage in meaningful work impacting patient care.
• Participate in a supportive and innovative team culture.