Job Description Summary

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The Medical Director Utilization Management (UM) is responsible for conducting clinical reviews of medical necessity, appropriateness, and efficiency of healthcare services, procedures, and hospital admissions. The reviewer ensures that clinical decisions align with established evidence-based guidelines, regulatory requirements, and organizational policies to promote optimal healthcare outcomes and cost-effective care.

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How will you make an impact & Requirements

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Key Responsibilities:

• Conduct prospective, concurrent, and retrospective clinical reviews of medical services to determine medical necessity and appropriateness.
• Utilize evidence-based criteria (e.g., MCG, InterQual, CMS guidelines) in evaluating requests for services.
• Collaborate with nurses, case managers, and other healthcare professionals in the UM process.
• Provide timely peer-to-peer consultations with requesting providers to discuss clinical decisions and alternative care options.
• Participate in appeals and grievance processes by reviewing denied cases and

providing justification based on medical necessity and standards of care.

• Ensure all reviews are performed in compliance with federal and state regulations, accreditation standards (e.g., NCQA, URAC), and organizational policies.
• Document decisions clearly and accurately in the appropriate systems.
• Identify patterns of inappropriate utilization and collaborate in quality improvement initiatives.
• Participate in staff training, UM committee meetings, and policy development as

needed.

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Compensation:

$134.55

to

$201.83