Location: Fully Remote | Candidates must be available to work Eastern Time (EST) business hours.
Hours: Part-time hours
Description:
Impresiv Health is seeking an experienced physician leader for a remote Medical Director, Utilization Management (Home Health, Acute & Post-Acute) role. In this position, you will serve as the primary clinical authority for home health authorization requests while supporting acute, post-acute, and outpatient medical necessity reviews for Medicare Advantage populations.
Working closely with the Home Health RN Lead, UM nursing staff, and network providers, you will apply CMS regulations, National/Local Coverage Determinations (NCD/LCD), Milliman Care Guidelines (MCG), and health plan medical policies to drive evidence-based care, ensure appropriate resource utilization, and improve health outcomes.
What You Will Do:
Clinical Reviews & Determinations:
Evaluate outpatient referrals, inpatient direct admissions, and home health authorization requests for medical necessity.
Conduct peer-to-peer discussions with treating physicians and providers to discuss clinical coverage criteria, alternative care plans, and complex cases.
Apply CMS guidelines, MCG criteria, and health plan medical policies to deliver accurate, timely coverage determinations.
Clinical Leadership & Nursing Collaboration:
Serve as the trusted physician advisor to the Home Health RN Lead and UM nursing staff, offering coaching, clinical mentoring, and complex case guidance.
Partner with external Home Health agency leadership to promote documentation standards and alignment with evidence-based care guidelines.
Policy & Quality Improvement:
Contribute to the ongoing refinement of utilization management clinical guidelines, medical policies, and best practices.
Collaborate with clinical operations leadership to support quality improvement initiatives and optimize care delivery through tech-enabled solutions.
You Will Be Successful If:
You possess deep clinical expertise in home health, post-acute care, and Medicare Advantage regulations, enabling confident peer-to-peer discussions and complex medical necessity determinations.
You act as an approachable, expert mentor to clinical nursing teams, elevating overall reviewer accuracy and case evaluation quality.
You bring a collaborative, tech-forward, and data-driven approach to medical management, seamlessly navigating digital authorization workflows and EHR environments.
What You Will Bring:
- MD or DO from an accredited school of medicine.
- Active, unrestricted state medical license (MD/DO) in any US jurisdiction.
- Board Certification in Internal Medicine, Family Medicine, Physical Medicine & Rehabilitation (PM&R), Emergency Medicine, or a closely related specialty.
- Minimum of 5+ years of direct clinical patient care experience.
- At least 1–2+ years of prior experience as a physician reviewer in Utilization Management.
- Direct experience reviewing Home Health medical necessity, as well as acute and post-acute services under Medicare Advantage guidelines.
- Expert command of CMS coverage criteria, NCDs/LCDs, and MCG guidelines.
- Strong peer-to-peer communication, relationship-building, and multi-disciplinary leadership abilities.
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That’s Impresiv!