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Medical Director, Utilization Management – Commercial & MA
HJ StaffingMedical Director leading utilization management in a high-impact contract role for a health plan. Focus on clinical integrity and care determinations for Commercial and Medicare Advantage members.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical necessity determinations and utilization management, with a strong focus on compliance with Medicare Advantage regulations and guidelines. Possesses advanced clinical judgment and communication skills to effectively collaborate with healthcare teams and improve care transitions.
Highest-signal resume keywords
Active M.D. Or D.O. DegreeBoard Certification In Medical SpecialtyUtilization Management ExperienceMCG Guidelines ExpertiseMedicare Advantage Regulations Knowledge
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity DeterminationClinical JudgmentUtilization ManagementPeer-To-Peer DiscussionsDocumentation ComplianceQuality Improvement InitiativesData-Driven AnalysisAttention To Detail
Soft Skills
Exceptional Communication SkillsProblem-Solving Abilities
Tools & Technologies
Medical Management PlatformsEnterprise ApplicationsMicrosoft Office Products
Certifications & Qualifications
Active Medical LicenseBoard Certification
Industry Keywords
Medicare AdvantageCommercial Health PlansUtilization Management MandatesClinical PracticeManaged Care
About the role
Key responsibilities & impact- Conduct timely medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings for Commercial and Medicare Advantage populations
- Apply nationally recognized guidelines to ensure appropriate level-of-care determinations
- Serve as the lead physician reviewer for complex, high-risk, or potentially adverse UM cases requiring clinical judgment
- Conduct peer-to-peer discussions with attending and treating physicians to clarify documentation, discuss options, and align on appropriate care plans
- Partner with Care Management and UM teams to identify utilization trends, reduce avoidable readmissions/extended stays, and streamline care transitions
- Offer clinical expertise to support quality improvement initiatives, regulatory audit preparedness, policy development, and UM committee activities
- Maintain precise, compliant, and timely documentation of all reviews and rationales in accordance with federal, state, and organizational guidelines.
Requirements
What you’ll need- Active M.D. or D.O. degree with an active, unrestricted medical license in good standing (in state of residence)
- Current Board Certification in an appropriate medical specialty
- Minimum of 5 years of clinical practice, including at least 3 years of direct experience in utilization management, physician review, or medical leadership within a managed care or health plan setting
- Demonstrated physician-level experience supporting Commercial and/or Medicare Advantage lines of business
- Advanced expertise with MCG guidelines and strong working knowledge of InterQual and CMS criteria
- Deep understanding of Medicare Advantage regulations, Commercial health plan benefit structures, and state/federal UM mandates
- Experience navigating medical management platforms, enterprise applications, and Microsoft Office products
- Exceptional written and oral communication skills
- Strong problem-solving abilities, attention to detail, and a data-driven approach to identifying utilization trends and quality gaps.
Benefits
Comp & perks- 100% remote work
- High-impact contract opportunity
- Immediate start