医疗总监 (使用管理)
Medical Director (Utilization Management)
HJ Staffing 正在紧急寻找一位医疗资源管理医学总监加入一家领先的医保优势健康计划。这位医生领导者将在确保住院和后期护理审查的临床完整性方面发挥关键作用，评估医疗必要性以支持最佳结果和监管合规性。
地点：100% 远程
时间：全职，周一至周五（必须工作太平洋标准时间）
职位描述
向首席医学官汇报，医学总监负责评估医保优势会员的医院入院、持续住院和后期护理服务。您将使用 CMS 规定和循证实践（MCG/InterQual）指导及时的护理决定，同时与护理管理团队和外部提供者合作。
您将负责的工作
- 临床审查：对住院入院和后期护理环境（SNF、IRF、LTACH 和居家健康）进行及时的医疗必要性评估。
- 标准应用：使用循证指南（MCG/InterQual）和 CMS 标准评估急性护理服务的适当性。
- 同行交流：与主治医生进行讨论，澄清临床记录并支持适当的护理水平。
- 复杂案例管理：作为主要医生评审员处理需要专家医学判断的升级或复杂 UM 案例。
- 协作：与资源管理和护理管理团队合作，确保一致且成本有效的护理，并参与 UM 委员会会议。
- 合规与文档：确保所有决策符合 NCQA 和 CMS 要求；支持审计准备和授权监督。
- 资源使用趋势：识别护理模式并支持干预措施，以减少不必要的入院或延长住院时间。
您将带来的条件
- 资质：在您常住州持有效执照的 M.D. 或 D.O.
- 临床经验：至少 5 年的临床经验。
- 管理护理专长：至少 3 年在管理护理或医疗领导岗位的经验，工作环境为管理护理或健康计划。
- 专业技能：在住院/后期护理案例审查方面有丰富经验，深入了解医保优势法规和 CMS 覆盖标准。
- 技术技能：熟练掌握 MCG 指南，以及 MS Office 和医疗管理软件的高级技能。
- 教育（优先）：MPH、MBA 或 MHA；认证要求
查看英文原文
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.
Location: 100% Remote
Schedule: Full-Time, Monday – Friday (Must work PST hours)
Job Description
Reporting to the Chief Medical Officer, the Medical Director focuses on Evaluating hospital admissions, continued stays, and post-acute services for Medicare Advantage members. You will guide timely care determinations using CMS regulations and evidence-based practices (MCG/InterQual) while collaborating with care management teams and external providers.
What You Will Do
- Clinical Review: Conduct timely medical necessity determinations for inpatient admissions and post-acute settings (SNF, IRF, LTACH, and Home Health).
- Criteria Application: Use evidence-based guidelines (MCG/InterQual) and CMS criteria to assess the appropriateness of acute care services.
- Peer-to-Peer: Lead discussions with attending physicians to clarify clinical documentation and support appropriate levels of care.
- Complex Case Management: Serve as the primary physician reviewer for escalated or complex UM cases requiring expert medical judgment.
- Collaboration: Partner with utilization and care management teams to ensure consistent, cost-effective care and participate in UM committee meetings.
- Compliance & Documentation: Ensure all decisions are documented according to NCQA and CMS requirements; support audit preparedness and delegated oversight.
- Utilization Trends: Identify patterns in care and support interventions to reduce unnecessary admissions or extended stays.
What You Will Bring
- Credentials: Licensed M.D. or D.O. in good standing in your state of residence.
- Clinical Experience: Minimum of 5 years of clinical experience.
- Managed Care Expertise: At least 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
- Specialized Knowledge: Strong experience in inpatient/post-acute case review and deep knowledge of Medicare Advantage regulations and CMS coverage criteria.
- Technical Skills: Extensive experience with MCG guidelines and advanced proficiency in MS Office and medical management software.
- Education (Preferred): MPH, MBA, or MHA; Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
You Will Be Successful If:
- You are an expert in using data to design and implement clinical programs and population health management.
- You possess strong negotiation skills, particularly in physician-to-physician interactions.
- You thrive in a matrix organization and can mentor staff while making independent, high-stakes decisions.
- You have a meticulous eye for detail and can maintain a reasonable rate of speed in a fast-paced, high-volume environment.
- You are committed to the highest standards of confidentiality and clinical documentation.
Originally posted on Himalayas