Medical Director, Utilization Management – Commercial & MA

Bickham Services Unlimited, LLC

Medical Director leading utilization management and ensuring appropriate care determinations for commercial and Medicare Advantage members. Collaborating with teams to support optimal outcomes and compliance.

Posted 7/25/2026contractRemote • Nevada • 🇺🇸 United StatesLeadWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in utilization management for Commercial and Medicare Advantage populations, with a strong focus on clinical assessments, regulatory compliance, and evidence-based guidelines. Capable of conducting complex case reviews and collaborating effectively with healthcare teams to ensure appropriate care delivery.

Highest-signal resume keywords

Utilization Management ExperienceClinical ExperienceM.D. Or D.O. DegreeBoard CertificationKnowledge Of Medicare Advantage Regulations

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Inpatient Case ReviewsPost-Acute Case ReviewsMedical Necessity DeterminationEvidence-Based Guidelines ApplicationClinical DocumentationRegulatory ComplianceAudit PreparednessQuality Improvement InitiativesTrend IdentificationUtilization Management Protocols

Soft Skills

CollaborationCommunicationClinical JudgmentPeer-To-Peer Discussion

Tools & Technologies

MCGInterQualCMS CriteriaNCQA Standards

Certifications & Qualifications

Active Medical LicenseBoard Certification In Medical Specialty

Industry Keywords

Commercial Health Plan BenefitsMedicare AdvantageUtilization ManagementManaged CareClinical Guidelines

About the role

Key responsibilities & impact

Conduct timely utilization reviews and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings, including SNF, IRF, LTACH, and home health, for Commercial and Medicare Advantage members.
Assess the appropriateness of acute and post-acute services using evidence-based guidelines, including MCG and InterQual, as well as applicable CMS criteria, Commercial medical policies, coverage guidelines, and member benefit plans.
Apply the appropriate regulatory and coverage standards based on the member’s line of business.
Serve as the physician reviewer for escalated, complex, or potentially adverse utilization management cases requiring medical judgment.
Collaborate with utilization management and care management teams to promote consistent, clinically appropriate, and cost-effective care.
Participate in peer-to-peer discussions with treating and attending physicians to clarify clinical documentation and support appropriate levels of care.
Identify trends in care utilization and support interventions designed to reduce avoidable admissions, readmissions, extended stays, and unnecessary healthcare expenditures.
Provide clinical input into the development, interpretation, and implementation of medical policies, clinical guidelines, and utilization management protocols.
Support regulatory compliance, audit preparedness, accreditation requirements, and delegated oversight for Commercial and Medicare Advantage utilization management functions.
Contribute clinical expertise to quality improvement initiatives involving utilization patterns, readmission reduction, care transitions, and member outcomes.
Document all reviews, determinations, and clinical rationales in accordance with CMS, NCQA, applicable state and federal requirements, and organizational policies.
Participate in utilization management committee meetings and represent the health plan in provider, regulatory, and external stakeholder engagements as needed.

Requirements

What you’ll need

Utilization management experience supporting Commercial and/or Medicare Advantage populations.
Minimum of five years of clinical experience, including at least three years in utilization management, physician review, or medical leadership within a managed care or health plan setting.
An M.D. or D.O. degree with an active, unrestricted medical license in good standing in the state of residence.
Current board certification in an appropriate medical specialty.
Strong experience conducting inpatient and post-acute case reviews and determining the medical necessity and appropriateness of acute and post-acute services.
Knowledge of Commercial health plan benefits, coverage guidelines, medical policies, and applicable state and federal requirements.
Knowledge of Medicare Advantage regulations and CMS coverage criteria.
Experience applying evidence-based clinical guidelines such as MCG or InterQual.
Experience conducting peer-to-peer discussions and communicating adverse or complex clinical determinations.

Benefits

Comp & perks

Fully remote opportunity
Immediate start