Location: 100% remote, but candidates must be comfortable working PST hours.
Description:
Impresiv Health is seeking an experienced Medicare Advantage Utilization Management (UM) Physician Medical Director to provide physician-level clinical leadership, oversight, and decision-making for prior authorization, concurrent review, retrospective review, and appeals programs.
This role serves as the clinical authority for medical necessity determinations that cannot be approved by RN reviewers. The Physician Medical Director conducts peer-to-peer discussions with treating providers and collaborates with utilization management leadership to ensure timely, clinically sound, and cost-effective determinations consistent with evidence-based guidelines, applicable regulatory requirements, and NCQA/URAC accreditation standards.
The Medical Director will also contribute to program strategy, medical policy development, quality oversight, provider education, and continuous improvement of utilization management operations.
What You Will Do:
Clinical Review & Medical Necessity Determinations
- Perform physician-level medical necessity reviews of prior authorization requests, concurrent inpatient reviews, and retrospective reviews referred by RN reviewers when clinical criteria are not clearly met.
- Render timely clinical determinations consistent with Medicare guidelines, nationally recognized clinical criteria (MCG), evidence-based guidelines, health plan policies, standards of care, and applicable state and federal turnaround-time requirements.
- Conduct peer-to-peer discussions with attending physicians and treating providers before issuing adverse determinations, ensuring that clinical rationale is clearly documented and defensible.
- Serve as a physician reviewer for first-level appeals and refer cases to independent or specialty peer review when required.
- Participate in Administrative Law Judge (ALJ) hearings as required.
- Maintain availability for urgent and expedited reviews within required regulatory turnaround windows.
Utilization Management Leadership & Program Oversight
- Partner with UM leadership, nursing leadership, Medical Policy, and Grievance and Appeals departments to establish clinical review policies, escalation pathways, and clinical criteria adoption or customization.
- Provide clinical guidance and mentorship to RN reviewers and intake staff, serving as a point of escalation for complex or ambiguous cases.
- Participate in interrater reliability (IRR) testing and calibration sessions to ensure consistent application of clinical criteria across the review team.
- Support workforce and capacity planning by advising on case complexity trends, criteria changes, and clinical review time standards.
- Supervise and manage assigned personnel, including hiring, performance evaluations, corrective actions, and staff development, as applicable.
- Contribute to organizational goals, operational initiatives, and the ongoing improvement of utilization management programs.
- Support the evaluation and responsible adoption of AI-enabled solutions to improve healthcare operations and member services.
- Perform other duties as assigned.
Quality, Compliance & Accreditation
- Ensure utilization management decisions and documentation meet NCQA/URAC accreditation standards and applicable state and federal regulatory requirements, including CMS, state Department of Insurance (DOI), and Medicaid rules, as applicable.
- Participate in UM Committees, Quality Improvement Committees, and UM data discussions, presenting clinical outcomes, denial trends, and appeal overturn-rate data.
- Support internal and external audits, regulatory examinations, and delegation oversight reviews related to utilization management.
- Identify and help remediate patterns of inappropriate utilization, quality-of-care concerns, or potential fraud, waste, and abuse, escalating concerns as appropriate.
- Promote consistent, evidence-based clinical decision-making and maintain compliance with established medical necessity criteria and regulatory standards.
Provider Relations & Education
- Communicate professionally and collaboratively with network and non-network providers regarding clinical review determinations and medical necessity criteria.
- Support provider education regarding utilization management policies, submission requirements, and clinical documentation expectations to reduce avoidable denials.
- Represent the utilization management program in provider disputes, credentialing and quality committees, and external clinical forums as needed.
- Collaborate with internal and external stakeholders to improve provider communication, documentation accuracy, and utilization management effectiveness.
You Will Be Successful If:
- You demonstrate sound, well-documented clinical judgment and consistently apply evidence-based medical necessity criteria to complex clinical cases.
- You possess a strong understanding of Medicare Advantage utilization management, including Medicare coverage policies, regulatory requirements, and medical necessity determinations.
- You effectively manage high-volume, deadline-driven clinical review queues while meeting strict regulatory turnaround-time requirements.
- You communicate clinical rationale clearly and professionally to providers, members, and non-clinical stakeholders.
- You demonstrate strong analytical skills, business insight, and effective problem-solving capabilities.
- You collaborate effectively with multidisciplinary teams, including physicians, RN reviewers, intake staff, and operational leadership.
- You provide clinical mentorship, guidance, and oversight to support consistent decision-making across the review team.
- You identify opportunities to improve clinical quality, operational efficiency, regulatory compliance, and utilization management outcomes.
- You maintain thorough, accurate, and defensible documentation supporting clinical determinations and appeals.
- You demonstrate an in-depth understanding of healthcare operations and regulatory, compliance, and accreditation requirements applicable to utilization management programs.
- You are proficient with utilization management and clinical workflow platforms, electronic health records, and standard office productivity software.
- You demonstrate a collaborative leadership style and the ability to support clinical team performance and professional development.
What You Will Bring:
Education & Licensure
- Graduate of an accredited medical school.
- Current, active, unrestricted Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) license.
- Willingness to obtain additional state medical licenses as required by the role.
- Board certification in good standing in a relevant specialty, such as Internal Medicine, Family Medicine, or Emergency Medicine.
Required Experience
- Minimum of 5 years of active clinical practice experience in Internal Medicine, Family Medicine, or Emergency Medicine.
- Minimum of 2–3 years of utilization management, case management, or managed care experience, including medical necessity reviews and peer-to-peer clinical discussions within a health plan environment.
- Experience with Medicare Advantage utilization management and medical necessity determinations.
- Working knowledge of nationally recognized medical necessity criteria, including MCG.
- Strong understanding of utilization management regulatory and accreditation frameworks, including NCQA, URAC, and CMS requirements.
- Working knowledge of Medicare decision-making requirements, including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and the Medicare Benefit Policy Manual.
- Experience applying clinical criteria and evidence-based guidelines to medical necessity reviews, authorization decisions, and appeals.
- Ability to document clinical determinations clearly, accurately, and in compliance with regulatory requirements.
Preferred Qualifications
- Prior experience as a Medical Director or Associate Medical Director within a health plan, Independent Practice Association (IPA), Third-Party Administrator (TPA), or Medicare Managed Care Organization.
- Candidates located in California are preferred.
- Additional board certification or subspecialty training relevant to the health plan's membership, including hospital medicine, geriatrics, or behavioral health.
- Experience with appeals and grievances, external review processes, and state fair hearing participation.
- Familiarity with population health management, value-based care arrangements, or risk-adjustment programs.
- Advanced analytical skills and an in-depth understanding of healthcare business operations.
- Strong verbal and written communication skills, interpersonal skills, and problem-solving abilities.
- Experience mentoring or supervising multidisciplinary clinical review teams.
- Proficiency with utilization management platforms, clinical workflow systems, electronic health records, and productivity software.
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!