The posting
This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Medical Director, Utilization Management (Home Health, Acute & Post-Acute) based in United States.
This role offers an opportunity for an experienced physician leader to serve as a key clinical authority within a remote utilization management environment. You will oversee medical necessity reviews for home health services while also supporting acute, post-acute, and outpatient reviews for Medicare Advantage populations. The position combines clinical decision-making, physician-to-physician collaboration, nursing mentorship, and evidence-based utilization management. You will apply CMS regulations, National and Local Coverage Determinations, MCG guidelines, and health plan medical policies to complex clinical cases. Working closely with nursing teams and provider organizations, you will help promote appropriate care, effective resource utilization, and positive health outcomes. The role also provides opportunities to contribute to clinical policy development, quality improvement, and technology-enabled care management initiatives. This is a fully remote, part-time position requiring availability during Eastern Time business hours.
Accountabilities:
- Evaluate outpatient referrals, inpatient direct admissions, and home health authorization requests to determine medical necessity and appropriate levels of care.
- Conduct peer-to-peer discussions with treating physicians and other providers regarding clinical coverage criteria, alternative care plans, and complex cases.
- Apply CMS requirements, National and Local Coverage Determinations, MCG criteria, and applicable medical policies to make accurate and timely coverage determinations.
- Serve as a physician advisor to Home Health RN Leads and utilization management nursing teams, providing clinical guidance, mentoring, and support with complex cases.
- Collaborate with external home health agency leadership to promote appropriate documentation standards and alignment with evidence-based care practices.
- Support the ongoing development and refinement of utilization management guidelines, medical policies, and clinical best practices.
- Partner with clinical operations leadership on quality improvement initiatives and strategies to optimize care delivery.
- Help advance technology-enabled and data-informed approaches to medical management and utilization review.
- Promote consistency, clinical accuracy, and quality across medical necessity evaluations and reviewer workflows.
- MD or DO degree from an accredited medical school.
- Active, unrestricted medical license in at least one U.S. jurisdiction.
- Board certification in Internal Medicine, Family Medicine, Physical Medicine & Rehabilitation, Emergency Medicine, or a closely related specialty.
- At least 5 years of direct clinical patient care experience.
- 1–2+ years of prior experience working as a physician reviewer in utilization management.
- Direct experience evaluating home health medical necessity and reviewing acute and post-acute services within Medicare Advantage populations.
- Advanced knowledge of CMS coverage requirements, National Coverage Determinations, Local Coverage Determinations, and MCG guidelines.
- Strong understanding of evidence-based utilization management and medical necessity principles.
- Excellent peer-to-peer communication, relationship-building, facilitation, and multidisciplinary collaboration skills.
- Ability to provide approachable, effective clinical mentorship to nursing and utilization management teams.
- Strong clinical judgment and ability to navigate complex cases, coverage criteria, and alternative care options.
- Comfortable working with digital authorization workflows, electronic health record environments, and technology-enabled clinical management tools.
- Data-driven, collaborative, and adaptable approach to medical management.
- Availability to work part-time during Eastern Time business hours.
- Fully remote work environment.
- Part-time schedule designed around Eastern Time business hours.
- Opportunity to provide clinical leadership across home health, acute, post-acute, and outpatient utilization management.
- Ability to influence evidence-based care, appropriate resource utilization, and health outcomes.
- Collaboration with experienced physicians, nurses, clinical leaders, and healthcare providers.
- Opportunity to contribute to utilization management policy development and quality improvement initiatives.
- Exposure to technology-enabled and data-driven approaches to clinical management.
- Leadership and mentoring opportunities within multidisciplinary clinical teams.
How Jobgether works:
We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.
We appreciate your interest and wish you the best!
Why Apply Through Jobgether?
Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.
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