Utilization Review Medical Director

Job Summary

To support Utilization Management operations, the full-time Utilization Review Medical Director will conduct clinical reviews of Durable Medical Equipment (DME) requests remotely, ensuring compliance with Medicare and Medicaid guidelines while maintaining productivity and accuracy standards.

Key responsibilities

• Conduct timely clinical reviews of DMEPOS authorization requests using applicable criteria and internal policies
• Maintain continuous case throughput in a high-volume review queue, adhering to organizational turnaround and productivity standards
• Document clinical decisions clearly and participate in Peer-to-Peer discussions to support complex case reviews

Required qualifications

• MD or DO degree with board certification in Internal Medicine, Family Medicine, or Physical Medicine & Rehabilitation
• Eligibility for participation in Medicare, Medicaid, and other federally funded programs without current or past sanctions
• Experience in utilization management or clinical review activities, particularly with DMEPOS reviews
• Familiarity with NCQA UM accreditation standards and electronic UM systems
• Ability to work effectively in a high-volume, queue-based workflow