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Responsibilities
Job Description:
Medical Director – Utilization Management
Performed comprehensive medical necessity reviews and utilization management determinations for Commercial, Medicare Advantage (MA), Federal Employee Program (FEP), and Appeals lines of business, ensuring compliance with clinical guidelines, regulatory requirements, and organizational policies.
Conducted peer-to-peer consultations and physician reviews to evaluate prior authorization requests, inpatient admissions, continued stays, and complex medical cases while making evidence-based coverage determinations.
Managed high-volume transactional case reviews, providing timely, accurate, and clinically sound decisions to support quality patient care and appropriate healthcare resource utilization.
Collaborated with care management, case management, pharmacy, provider services, and clinical operations teams to resolve complex medical issues and improve member outcomes.
Interpreted and applied nationally recognized evidence-based clinical criteria, medical policies, and utilization management guidelines to ensure consistent and compliant decision-making.
Participated in on-call rotations to provide clinical support and timely coverage determinations across multiple lines of business.
Worked closely with internal stakeholders to identify utilization trends, recommend process improvements, and support quality assurance initiatives.
Reviewed complex appeals, escalated cases, and disputed coverage determinations while ensuring adherence to state, federal, and accreditation standards.
Leveraged healthcare technology platforms and utilization management systems to document clinical decisions, improve workflow efficiency, and maintain accurate case records.
Supported government and commercial health plan operations by ensuring appropriate utilization of healthcare services while balancing quality of care, regulatory compliance, and cost-effectiveness.
Maintained productivity, quality, and turnaround time metrics while contributing to continuous improvement initiatives across utilization management operations.
Provided clinical expertise and guidance to multidisciplinary teams, promoting evidence-based decision-making and operational excellence.
Qualifications
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) from an accredited medical school.
Active, unrestricted physician license (North Carolina license preferred).
7+ years of clinical experience within healthcare insurance, utilization management, or managed care.
Strong experience performing utilization management reviews, prior authorization, medical necessity determinations, and appeals.
Experience supporting both government and commercial health plans, including Medicare Advantage and Commercial lines of business.
Proficient with healthcare technology platforms, electronic medical records (EMR/EHR), and utilization management systems.
Excellent analytical, clinical judgment, communication, and peer-to-peer consultation skills.
Ability to manage high-volume, detail-oriented transactional work while maintaining quality and regulatory compliance.
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