| Job Summary:
The Medical Director of Utilization Management (UM) serves as the physician lead for medical necessity review, level-of-care determination, and clinical escalation across the care continuum. This role provides expert second-level reviews, participates in peer-to-peer discussions with payer medical directors, and collaborates closely with case management and revenue cycle teams to reduce denials and improve clinical alignment with utilization policies.
Working in partnership with the UM nursing team and executive leadership, the Medical Director ensures consistency in clinical decision-making, supports appeal strategy, and champions compliance with regulatory and payer criteria. This role bridges the gap between clinical operations and administrative oversight, driving efficiency, cost containment, and quality outcomes across inpatient care delivery.
Primary duties and responsibilities:
Second-Level Medical Necessity Reviews:
1. Conduct timely second-level reviews of inpatient, observation, and other cases escalated by UM staff.
2. Evaluate clinical appropriateness and ensure alignment with evidence-based criteria.
Peer-to-Peer and Payer Communication:
1. Lead peer-to-peer reviews with payer medical directors and provide clinical input for contested cases.
2. Support resolution of prior authorization disputes, denials, and appeal escalations.
Interdisciplinary Collaboration with UM & Case Management:
1. Partner with UM nurses, case managers, and inpatient teams to drive consistent level-of-care determinations and reduce delays in care.
Revenue Cycle and Denials Strategy Partnership:
1. Collaborate with Revenue Cycle leadership to identify trends in medical necessity denials, support appeal strategies, and inform documentation best practices.
Policy, Protocol, and Criteria Development:
1. Contribute to the development and periodic review of UM policies, medical necessity criteria, and care guidelines to ensure regulatory compliance.
Clinical Education and Stakeholder Engagement:
1. Educate physicians and staff on utilization review processes, payer expectations, and opportunities to improve documentation and reduce denials.
Data Review and Performance Reporting:
1. Monitor utilization trends, denial metrics, and clinical outcomes; use data to support process improvement and strategy development.
Additional Duties As Assigned.
Travel: <10% of the time may be required.
Work Type: Hybrid employee - splits time between working remotely and working in the office.
Minimum Required Qualifications:
Education - Graduate of an accredited school of Medicine. D.O./M.D. Degree required.
Experience - 5 years' minimum experience within a clinical setting
Licensure - Must have an active license to practice medicine in the State of Georgia
Knowledge, skills, and abilities (required):
- Utilization Review Expertise: Deep knowledge of evidence-based guidelines, InterQual/MCG criteria, and payer requirements to ensure appropriate level of care, medical necessity, and compliance with regulatory standards.
- Regulatory and Compliance Knowledge: Strong understanding of CMS regulations, Conditions of Participation, Two-Midnight Rule, and state/federal utilization review mandates; ability to ensure organizational adherence.
- Appeals and Denials Management: Skilled in leading medical necessity appeals, collaborating with payers, and supporting teams in reducing clinical denials and optimizing reimbursement.
- Data-Driven Decision-Making: Ability to interpret utilization data, identify patterns of over- or under-utilization, and drive interventions that improve efficiency without compromising quality.
- Physician Engagement and Education: Proven ability to engage medical staff in appropriate utilization practices, provide feedback on documentation and level of care decisions, and foster accountability.
- System-Level Perspective: Experience balancing patient-centered care with organizational stewardship, ensuring alignment of utilization practices with quality, safety, and financial goals
Preferred Qualifications
Education - Master's Degree in Healthcare Administration, Business Administration or Public Health
Experience - 7 years' minimum within a clinical setting
Certification - Certification in Utilization Management or CDI
Knowledge, skills, and ability requirements (preferred):
- Completion of formal physician leadership / medical director
PHYSICAL REQUIREMENTS (Medium Max 25lbs): up to 25 lbs., 0-33% of the work day (occasionally) Lifting 25 lbs. max; Carrying of objects up to 25 lbs.; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS: Factors affecting environmental conditions may vary depending on the assigned work area and tasks. Environmental exposures include but are not limited to: Blood-borne pathogen exposure, Bio-hazardous waste chemicals/gases/fumes/vapors, Communicable diseases, Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks. |
Human Resources