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.