Medical Director

• Conduct timely utilization review and medical necessity determinations for inpatient admissions , continued stays , and post-acute care services (SNF, IRF, LTACH, home health) for Medicare Advantage members.
• Apply MCG and InterQual guidelines as well as CMS criteria to assess the appropriateness of acute care services.
• Serve as the physician reviewer for complex or escalated UM cases requiring clinical judgment.
• Collaborate with utilization and care management teams to ensure consistent, cost-effective, and patient-centered care decisions.
• Participate in peer-to-peer discussions with attending physicians to clarify documentation and support proper levels of care.
• Identify utilization trends and assist in developing interventions to reduce unnecessary admissions or extended stays.
• Contribute to the development and implementation of medical policy and UM protocols.
• Support CMS regulatory compliance , audit preparedness, and delegated oversight activities.
• Participate in UM committee meetings and represent the organization in provider or stakeholder engagements.
• Ensure all documentation meets NCQA , CMS , and internal standards.

Medical Director, Utilization Management

Clinical Director

Medical Director – IP Claims Management

Medical Director – Scientific Affairs

Medical Director, Appeals

Inpatient Medical Director