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Clinical Review:
- Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
- Use evidence-based guidelines ( MCG/InterQual ) and CMS criteria to assess the appropriateness of acute care services.
Criteria Application:
- Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
- Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
Compliance & Documentation:
- Ensure all decisions are documented according to NCQA and CMS requirements.
- Support audit preparedness and delegated oversight.
HJ Staffing
HJ Staffing is urgently seeking a Medical Director of Utilization Management to join a leading Medicare Advantage Health Plan. This physician leader will play a critical role in ensuring the clinical integrity of inpatient and post-acute care reviews, evaluating medical necessity to support optimal outcomes and regulatory compliance.