Medical Director (Utilization Management)

Location : 100% remote, but candidates must reside on the West Coast and comfortable working PST hours.

Description :

The Medical Director (Utilization Management) plays a critical role in leading and supporting the clinical integrity of the utilization management function, with a specific focus on inpatient and post-acute care reviews. This physician leader ensures timely and appropriate care determinations for Medicare Advantage members, guided by clinical criteria, CMS regulations, and evidence-based practices.

Reporting to the Chief Medical Officer, this role focuses on evaluating medical necessity and appropriateness of hospital admissions, continued stays, and post-acute services. The Medical Director collaborates with care management teams, providers, and internal stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, and regulatory compliance.

What You Will Do :

• Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings (e.g., SNF, IRF, LTACH, home health) for Medicare Advantage members
• Assess appropriateness of acute care services using evidence-based guidelines (e.g., MCG, InterQual) and CMS criteria
• Serve as the physician reviewer for escalated or complex UM cases requiring medical judgment
• Collaborate with utilization management and care management teams to ensure consistent, clinically appropriate, and cost-effective care
• Participate in peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate levels of care
• Identify trends in care utilization and support the development of interventions to reduce unnecessary admissions or extended stays
• Provide input into the development and implementation of medical policy and UM protocols
• Support CMS regulatory compliance, audit preparedness, and delegated oversight for UM functions
• Contribute clinical expertise to quality improvement initiatives related to utilization patterns, readmission reduction, and transitions of care
• Document all reviews and decisions according to NCQA, CMS, and organizational requirements
• Participate in UM committee meetings and represent the health plan in external provider and stakeholder engagements as needed

You Will Be Successful If :

What You Will Bring :

About Impresiv Health :

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate About Impresiv Health value, at a rate that cannot be beaten. Your success matters, and we know it.

That's Impresiv!