PRN Medical Director BH UM

How Will You Make An Impact & Requirements

• Conduct prospective, concurrent, and retrospective clinical reviews of medical services to determine medical necessity and appropriateness.
• Utilize evidence-based criteria (e.g., MCG, InterQual, CMS guidelines) in evaluating requests for services.
• Collaborate with nurses, case managers, and other healthcare professionals in the UM process.
• Provide timely peer-to-peer consultations with requesting providers to discuss clinical decisions and alternative care options.
• Participate in appeals and grievance processes by reviewing denied cases and providing justification based on medical necessity and standards of care.
• Ensure all reviews are performed in compliance with federal and state regulations, accreditation standards (e.g., NCQA, URAC), and organizational policies.
• Document decisions clearly and accurately in the appropriate systems.
• Identify patterns of inappropriate utilization and collaborate in quality improvement initiatives.
• Participate in staff training, UM committee meetings, and policy development as needed.