Medical Director – Utilization Management (UM)
Trispoke Managed Services Pvt. Ltd. · United States · 2 mo ago
RemoteRemoteHealthcareContract
We are seeking an experienced Medical Director for Utilization Management (UM) to join a leading healthcare organization. This is a contract-to-hire, full-time remote role based in the USA.
About the role
The ideal candidate will perform medical necessity reviews, utilization management, appeals, and peer-to-peer discussions. You will collaborate with multidisciplinary care teams while ensuring compliance with healthcare regulations.
Responsibilities
- Perform medical necessity reviews
- Conduct utilization management and appeals processes
- Engage in peer-to-peer discussions with providers
- Collaborate with multidisciplinary care teams
- Ensure compliance with healthcare regulations and guidelines (Managed Care, NCQA, CMS, URAC)
Requirements
- MD or DO degree
- Active medical license in PA, NY, or WV
- Board Certified (ABMS or AOA)
- 5+ years of direct patient care experience
- 1+ year of Utilization Management experience on the Health Insurance/Payer side
- Experience reviewing medical necessity, appeals, and peer-to-peer reviews
- Strong knowledge of Managed Care, NCQA, CMS, and URAC guidelines
- US Citizen
Preferred Qualifications
- Experience with MCG or InterQual
Schedule
- Full-time (40 hours/week), remote
- Core hours: 9 AM – 5 PM EST (flexible after training)