Medical Director, Utilization Management

Medical Director, Utilization Management

Location: New Jersey – Fully Remote
Work Arrangement: Remote
Job Type: Contract
Contract Length: 6–9 months, with potential for extension
Schedule: Standard business hours; schedule to be determined with the client
Start Date: Immediate / ASAP
Department: Healthcare – Utilization Management (Clinical)
Reports To: Chief Medical Officer
Openings: 1
Pay: Hourly, DOE

About the Position

Bickham Services Unlimited, LLC is seeking a Medical Director, Utilization Management to support a healthcare utilization management program serving Commercial and Medicare Advantage members.

The Medical Director will lead and support clinical utilization management activities, with a primary focus on inpatient and post-acute care reviews. This position is responsible for ensuring timely, consistent, and appropriate medical necessity determinations based on member benefit plans, medical policies, clinical criteria, CMS regulations, and evidence-based practices.

Key Responsibilities

• Conduct timely utilization reviews and medical necessity determinations for inpatient admissions and continued stays.


• Review post-acute care services, including SNF, IRF, LTACH, and home health.


• Evaluate the appropriateness of acute and post-acute services using MCG, InterQual, CMS criteria, commercial medical policies, and member benefit plans.


• Apply applicable regulatory and coverage standards based on the member's line of business.


• Serve as a physician reviewer for escalated, complex, or potentially adverse utilization management cases.


• Participate in peer-to-peer discussions with treating and attending physicians.


• Collaborate with utilization management and care management teams to support consistent and cost-effective care.


• Identify utilization trends and support initiatives designed to reduce avoidable admissions and readmissions.


• Provide clinical input regarding medical policies, clinical guidelines, and utilization management protocols.


• Support regulatory compliance, audit readiness, accreditation, and delegated oversight activities.


• Contribute to quality improvement initiatives involving utilization patterns, readmissions, and care transitions.


• Ensure reviews and determinations are appropriately documented in accordance with CMS, NCQA, and applicable state and federal requirements.


• Participate in utilization management committee meetings and represent the health plan externally when needed.
  

Minimum Qualifications

• Active, unrestricted M.D. or D.O. license in good standing.


• Current board certification in an appropriate medical specialty.


• At least 5 years of clinical experience, including at least 3 years of experience in utilization management, physician review, or medical leadership within a managed care or health plan environment.


• Physician-level utilization management experience supporting Commercial and/or Medicare Advantage populations.


• Strong experience with inpatient and post-acute care reviews and medical necessity determinations.


• Knowledge of commercial benefits, coverage requirements, and medical policies.


• Knowledge of Medicare Advantage and CMS coverage criteria.


• Experience applying MCG and/or InterQual guidelines.


• Experience conducting peer-to-peer discussions and communicating complex or adverse determinations.


• Candidate must reside in or hold applicable licensure for New Jersey.
  

Preferred Qualifications

• Master's degree such as MPH, MBA, or MHA.


• ABQAURP certification.


• Experience with quality improvement, regulatory compliance, accreditation, or delegated oversight.