Medical Director, Utilization Management

Job Summary

To support optimal member outcomes in Home Health services, the remote Medical Director, Utilization Management will manage authorization requests, ensure evidence-based decision-making, and collaborate with interdisciplinary teams while focusing on quality and resource utilization.

Key responsibilities

• Review authorization requests for Home Health, acute inpatient, post-acute, outpatient, and pharmacy services to determine medical necessity
• Serve as the primary physician reviewer for complex Home Health authorization requests and mentor Utilization Management nurses on case evaluations
• Collaborate with the Home Health RN Lead and cross-functional teams to improve clinical outcomes and support quality improvement initiatives

Required qualifications

• MD or DO degree with board certification in a relevant specialty and an unrestricted U.S. medical license
• 5+ years of clinical experience, including Utilization Management and Medicare Advantage experience
• Expertise in reviewing Home Health medical necessity using CMS regulations and Medicare coverage criteria
• Experience with acute, post-acute, outpatient, and/or pharmacy services
• Strong communication skills and a collaborative approach to improve member outcomes through innovative solutions