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Open nowPosted 4 hours agoWe saw it 92 min after it went up

Medical Director, Utilization Management (Home Health, Acute & Post-Acute) High

harris-jones-staffing-recruiting-llc29 open roles

Where
Eagan, Minnesota, United States
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Your applicationOpen nowMedical Director, Utilization Management (Home Health, Acute & Post-Acute) Highharris-jones-staffing-recruiting-llc · Eagan, Minnesota, United States

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The clock on this job

Early applications get read.

8.0% of postings close within 7 days. Measured by our own scanner across the market. harris-jones-staffing-recruiting-llc postings stay open a median of 3 days.

Share of postings closed within
  1. 1.6%1 day
  2. 3.5%3 days
  3. 8.0%7 days
  4. 15.0%14 days
  5. 34.1%30 days
This job: posted 4 hours ago

harris-jones-staffing-recruiting-llc median: 3 days open

The posting

HJ Staffing is seeking an experienced physician leader for a remote Medical Director, Utilization Management (Home Health, Acute & Post-Acute) role. In this position, you will serve as the primary clinical authority for home health authorization requests while supporting acute, post-acute, appeals, reconsiderations, and outpatient medical necessity reviews for Medicare Advantage populations.

Working closely with the Home Health RN Lead, UM nursing staff, and network providers, you will apply CMS regulations, National/Local Coverage Determinations (NCD/LCD), Milliman Care Guidelines (MCG), and health plan medical policies to drive evidence-based care, ensure appropriate resource utilization, and improve health outcomes.

Location: Fully Remote (Must be available during Eastern Time / EST business hours)

Employment Type: Part-Time / Contract (6-Month Contract with potential for extension)

Department: Clinical Operations / Utilization Management

What You Will Do:

Clinical Reviews & Determinations

  • Evaluate outpatient referrals, inpatient direct admissions, and home health authorization requests for medical necessity.
  • Review complex medical necessity denials, appeals, reconsiderations, and coverage determinations.
  • Conduct peer-to-peer discussions with treating physicians and providers to discuss clinical coverage criteria, alternative care plans, and complex cases.
  • Apply CMS guidelines, MCG criteria, and health plan medical policies to deliver accurate, timely coverage determinations.

Clinical Leadership & Nursing Collaboration

  • Serve as the trusted physician advisor to the Home Health RN Lead and UM nursing staff, offering coaching, clinical mentoring, and complex case guidance.
  • Partner with external Home Health agency leadership to promote documentation standards and alignment with evidence-based care guidelines.

Policy & Quality Improvement

  • Contribute to the ongoing refinement of utilization management clinical guidelines, medical policies, and best practices.
  • Collaborate with clinical operations leadership to support quality improvement initiatives and optimize care delivery through tech-enabled solutions.

What You Will Bring

  • Education: MD or DO from an accredited school of medicine.
  • Licensure: Active, unrestricted state medical license (MD/DO) in any U.S. jurisdiction.
  • Board Certification: Board Certification in Internal Medicine, Family Medicine, Physical Medicine & Rehabilitation (PM&R), Emergency Medicine, or a closely related specialty.
  • Clinical Experience: Minimum of 5+ years of direct clinical patient care experience.
  • UM Experience: At least 1–2+ years of prior experience as a physician reviewer in Utilization Management, including hands-on experience reviewing medical necessity denials and appeals.
  • Domain Expertise: Direct experience reviewing Home Health medical necessity, as well as acute and post-acute services under Medicare Advantage guidelines.
  • Regulatory & Guidelines Command: Expert knowledge of CMS coverage criteria, NCDs/LCDs, and MCG guidelines.
  • Communication & Tech Skills: Exceptional peer-to-peer communication abilities, strong multi-disciplinary leadership, and comfort navigating digital authorization workflows and EHR environments.

You Will Be Successful If You:

  • Possess deep clinical expertise in home health, post-acute care, and Medicare Advantage regulations, enabling confident peer-to-peer discussions and complex medical necessity determinations.
  • Act as an approachable, expert mentor to clinical nursing teams, elevating overall reviewer accuracy and case evaluation quality.
  • Bring a collaborative, tech-forward, and data-driven approach to medical management.
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