This physician leader conducts utilization management reviews for Medicare Advantage members, focusing on inpatient admissions, continued stays, concurrent review, and post-acute care settings such as SNF, IRF, LTACH, and home health. The role evaluates medical necessity and appropriate levels of care using clinical criteria, CMS requirements, and evidence-based guidelines. It also involves collaboration with care management teams, peer-to-peer discussions with treating physicians, and support for quality and compliance efforts.
Key Responsibilities
- Conduct timely medical necessity reviews for inpatient, concurrent, and post-acute care services.
- Assess appropriateness of acute care using MCG, InterQual, and CMS criteria.
- Serve as physician reviewer for complex or escalated utilization management cases.
- Participate in peer-to-peer discussions with attending physicians to clarify documentation and level-of-care decisions.
- Coordinate with utilization management and care management teams to support consistent, cost-effective care decisions.
- Identify utilization trends and contribute to interventions that reduce unnecessary admissions or extended stays.
- Support medical policy, UM protocols, audit readiness, and CMS regulatory compliance.
- Document reviews and decisions according to NCQA, CMS, organizational, and privacy requirements.
Required
- Licensed M.D. or D.O. in good standing in the state of residence.
- At least 5 years of clinical experience.
- At least 3 years of utilization management or medical leadership experience in a managed care or health plan setting.
- Experience with inpatient, post-acute, concurrent review, and Medicare Advantage case reviews.
- Knowledge of Medicare Advantage regulations and CMS coverage criteria.
- Experience using evidence-based clinical guidelines such as MCG or InterQual.
Preferred
- MPH, MBA, or MHA.
- ABQAURP certification.
Benefits & Perks
- 100% remote work arrangement.
- Opportunity to work with Medicare Advantage utilization management processes and clinical policy development.
- Physician leadership role reporting to the Chief Medical Officer.
- Collaboration with care management teams and external provider stakeholders.