Medical Director, Utilization Management

Medical Director, Utilization Management Location: New Jersey – Fully Remote Work Arrangement: Remote Job Type: Contract Contract Length: 6–9 months, with potential for extension Schedule: Standard business hours; schedule to be determined with the client Start Date: Immediate / ASAP Department: Healthcare – Utilization Management (Clinical) Reports To: Chief Medical Officer Openings: 1 Pay: Hourly, DOE About the Position Bickham Services Unlimited, LLC is seeking a Medical Director, Utilization Management to support a healthcare utilization management program serving Commercial and Medicare Advantage 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. • Physician-level utilization management experience supporting Commercial and/or Medicare Advantage populations. • Strong experience with inpatient and post-acute care reviews and medical necessity determinations. • Knowledge of commercial benefits, coverage requirements, and medical policies. • Knowledge of Medicare Advantage and CMS coverage criteria. • Experience applying MCG and/or InterQual guidelines. • Experience conducting peer-to-peer discussions and communicating complex or adverse determinations. • Candidate must reside in or hold applicable licensure for New Jersey. Preferred Qualifications • Master's degree such as MPH, MBA, or MHA. • ABQAURP certification. • Experience with quality improvement, regulatory compliance, accreditation, or delegated oversight. Salary: DOE Originally posted on Himalayas