Job Description
The Medical Director (Utilization Management) plays a critical role in leading and supporting the clinical integrity of the utilization management function, with a specific focus on inpatient and post-acute care reviews. This physician leader ensures timely and appropriate care determinations for Medicare Advantage members, guided by clinical criteria, CMS regulations, and evidence-based practices. Reporting to the Chief Medical Officer, this role focuses on evaluating medical necessity and appropriateness of hospital admissions, continued stays, and post-acute services. The Medical Director collaborates with care management teams, providers, and internal stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, and regulatory compliance.