Medical Director, Utilization Management

Job description

Medical Director, Utilization Management

Location: New Jersey – Fully Remote

Work Arrangement: Remote

Job Type: Contract

Contract Length: 6–9 months, with potential for extension

Schedule: Standard business hours; schedule to be determined with the client

Start Date: Immediate / ASAP

Department: Healthcare – Utilization Management (Clinical)

Reports To: Chief Medical Officer

Openings: 1

Pay: Hourly, DOE

About the Position

Bickham Services Unlimited, LLC is seeking a Medical Director, Utilization Management to support a healthcare utilization management program client serving members.

The Medical Director will lead and support clinical utilization management activities, with a primary focus on inpatient and post-acute care reviews. This position is responsible for ensuring timely, consistent, and appropriate medical necessity determinations based on member benefit plans, medical policies, clinical criteria, CMS regulations, and evidence-based practices.

Key Responsibilities

- Conduct timely utilization reviews and medical necessity determinations for inpatient admissions and continued stays.

- Review post-acute care services, including SNF, IRF, LTACH, and home health.

- Evaluate the appropriateness of acute and post-acute services using MCG, InterQual, CMS criteria, commercial medical policies, and member benefit plans.

- Apply applicable regulatory and coverage standards based on the member's line of business.

- Serve as a physician reviewer for escalated, complex, or potentially adverse utilization management cases.

- Participate in peer-to-peer discussions with treating and attending physicians.

- Collaborate with utilization management and care management teams to support consistent and cost-effective care.

- Identify utilization trends and support initiatives designed to reduce avoidable admissions and readmissions.

- Provide clinical input regarding medical policies, clinical guidelines, and utilization management protocols.

- Support regulatory compliance, audit readiness, accreditation, and delegated oversight activities.

- Contribute to quality improvement initiatives involving utilization patterns, readmissions, and care transitions.

- Ensure reviews and determinations are appropriately documented in accordance with CMS, NCQA, and applicable state and federal requirements.

- Participate in utilization management committee meetings and represent the health plan externally when needed.

Minimum Qualifications

- Active, unrestricted M. D. or D. O. license in good standing.

- Current board certification in an appropriate medical specialty.

- At least 5 years of clinical experience, including at least 3 years of experience in utilization management, physician review, or medical leadership within a managed care or health plan environment.

- Physician-level utilization management experience.

- Strong experience with inpatient and post-acute care reviews and medical necessity determinations.

- Knowledge of commercial benefits, coverage requirements, and medical policies.

- Experience applying MCG and/or InterQual guidelines.

- Experience conducting peer-to-peer discussions and communicating complex or adverse determinations.

- Candidate must reside in or hold applicable licensure for New Jersey.

Preferred Qualifications

- Master's degree such as MPH, MBA, or MHA.

- ABQAURP certification.

- Experience with quality improvement, regulatory compliance, accreditation, or delegated oversight.