Medical Director, Utilization Management

Job Summary

The Medical Director, Utilization Management provides clinical oversight of authorization decision making and processing, pre and post payment claims review activities, payment integrity clinical validation and program integrity functions. This position requires evaluation and insight for both medical and behavioral health cases.  In this position, the Medical Director supports the development of and ensures the application of clinical policies are consistent with evidence-based medicine and regulatory requirements. 

The Medical Director collaborates with internal teams to support timely consistent and defensible clinical decisions and promotion of appropriate high-value care.  In support of payment and program integrity initiatives, the Medical Director reviews clinical documentation to validate coding accuracy and appropriateness and completion of billed services.  This position plays a critical role in the mitigation of Fraud, Waste and Abuse (FWA) and requires proactive analysis of service level utilization data to identify trends, outliers and emerging risk areas and recommend corrective action to minimize utilization variation, prevent improper payments and ensure financial stewardship.

Works collaboratively with Health Services departments and key organizational stakeholders, to ensure alignment of utilization management, claims review, and regulatory compliance activities.

Partners with executive leadership, clinical teams, and external stakeholders to improve outcomes, support regulatory compliance, and advance organizational goals.

Duties

Provides physician leadership within the Health Services division, with primary responsibility for overseeing Utilization Management (UM) reviews, conducting medical claims review under Payment Integrity and supporting Behavioral Health (BH).

Applies clinical expertise and evidence-based criteria to behavioral health and medical/surgical services, conducting claims reviews in compliance with regulatory timeframe requirements.

Leads efforts to strengthen Payment Integrity by overseeing clinical validation of requested services, ensuring alignment between documentation and medical necessity. Analyzes utilization and claims data to identify trends, outliers, cost drivers, and opportunities to reduce unnecessary services and prevent improper payments.

Identifies and mitigates Fraud, Waste, and Abuse (FWA) risks by detecting patterns, and partners with internal teams as appropriate.

Develops, approves, and updates medical policies, procedures, and standards of care based on current, evidence-based practices.

Oversees and reviews the delivery of patient care to ensure it meets quality standards and regulatory guidelines.

Guides quality assurance and performance improvement (QAPI) programs and participates in quality review committees.

Maintains and enforces compliance with all federal and state laws, accreditation standards (such as NCQA), and other regulatory requirements.

Assists in the preparation and monitoring of departmental budgets, including managing costs and resource utilization.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 8 years of experience in medical management, managed care and quality management.

Experience in Payment Integrity.

Experience in maintaining liaison with Federal, State, and local bodies and medical organizations.

Experience in performance management and possession of strong analytic ability.

Extensive post-medical degree experience in clinical practice.

Significant experience in a clinical development, medical affairs, or management role within the biotech, pharmaceutical, or healthcare industry.

Proven experience in a physician leadership role, including managing teams.

Preferred: 

Experience with Medicaid managed care and/or governmental programs for underserved, safety net populations including women, children, person with disabilities, seniors, and those of varied ethnic and cultural backgrounds.

Skills

Required:

Ability to provide leadership to physicians, nurses, and other health care professionals, and an interest and involvement in the affairs of the health care community. 

Excellent written and verbal communication skills with the ability to effectively collaborate with multidisciplinary teams and senior leadership.

Strong leadership, consensus-building, and stakeholder engagement skills, as well as a commitment to evidence-based practice, continuous quality improvement, regulatory compliance, and health equity.

Demonstrated ability for teamwork and collaborative problem-solving.  

Commitment to patient-centered, value-based care.

Strong leadership presence with the ability to lead, mentor, and motivate a team.

Exceptional presentation skills to effectively convey complex medical concepts to diverse audiences.

Ability to think strategically and take a broad, business-oriented perspective.

Strong analytical and problem-solving skills, with a data-driven approach to evaluating programs.

Ability to work in a fast-paced, dynamic, and often ambiguous environment.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information