Medical Director, Utilization Management (Home Health, Acute & Post-Acute)
Core
Oversees medical necessity reviews for home health, acute, post-acute, and outpatient services within Medicare Advantage populations.
Role type
Senior physician leader (utilization management)
Builds
Clinical coverage determinations and utilization management guidelines
Domain
Healthcare / Utilization Management
Required skills
Medical necessity evaluation, peer-to-peer clinical discussions, CMS/NCD/LCD/MCG policy application, clinical mentorship, evidence-based care practices, quality improvement strategy, technology-enabled care management, complex case navigation, documentation standards alignment
Preferred skills
Data-driven approach, multidisciplinary collaboration, digital authorization workflows
Responsibilities
Evaluate outpatient referrals, inpatient direct admissions, and home health authorization requests; Conduct peer-to-peer discussions with treating physicians; Apply CMS requirements and coverage determinations; Serve as physician advisor to nursing teams; Collaborate with external agency leadership; Support development of utilization management guidelines; Partner on quality improvement initiatives; Advance technology-enabled medical management
Seniority
Senior, hands-on IC with leadership responsibilities
