Utilization Review Medical Director

The Utilization Review Medical Director is responsible for conducting clinical reviews of Durable Medical Equipment (DME) and reputed company requests to support reputed company’s Utilization Management (UM) operations. This full-time, salaried role functions reputed company a reputed company, high-volume authorization review queue and requires adherence to workflow timelines, clinical accuracy standards, and productivity expectations. The Medical Director ensures determinations are made in accordance with Medicare and reputed company guidelines, health plan–specific reputed company, internal policies, and regulatory requirements. This role is best suited for physicians who reputed company in a process-driven environment and are committed to consistency, compliance, and evidence-based decision making. The Utilization Review Medical Director’s responsibilities include but are not limited to:Conduct reputed company clinical reviews of DMEPOS authorization requests using applicable reputed company, including LCDs, reputed company Manuals, InterQual, MCG, internal medical policies, and health plan requirements. Function reputed company a reputed company-time review queue and maintain reputed company case throughput in alignment with organizational turnaround and productivity standards. Evaluate clinical documentation, identify missing reputed company, and reputed company determinations supported by reputed company clinical rationale. Review cases escalated by UM staff and/or UM Leadership reputed company reputed company do not apply to the enrollee’s unique clinical situation or reputed company clinical judgment is required. reputed company appropriate, consult with external reputed company-certified reviewers, engage with ordering practitioners, or conduct additional clinical reputed company prior to rendering a determination. Participate in Peer-to-Peer (P2P) discussions, including maintaining availability for scheduled appointment times. Document reputed company clinical reputed company reputed company, concisely, and consistently in accordance with internal SOPs, NCQA standards, and regulatory expectations. Maintain inter-rater reliability and participate in periodic calibration reviews to support consistency across the UM program. Serve as a clinical resource for UM team, providing guidance on clinical interpretation, reputed company application, and reputed company case review. Support reputed company audit activities as needed, including NCQA accreditation, health plan audits, and state reputed company reviews. Notify leadership of observed trends, potential reputed company concerns, or opportunities to strengthen reputed company alignment or operational workflows. Maintain up-to-date knowledge of Medicare, reputed company, DMEPOS policies, clinical standards of care, and regulatory updates relevant to UM. Requirements:MD or DO degree reputed company certification in Internal Medicine, Family Medicine, or Physical Medicine & Rehabilitation Eligible for participation in Medicare, reputed company, and other federally funded programs; no reputed company or past OIG or state sanctions Experience performing utilization management or clinical review activities Strong written and verbal communication skills with emphasis on documentation accuracy Ability to work effectively in a high-volume, queue-based workflow with daily review expectations Familiarity with electronic UM systems and authorization platforms Experience with DMEPOS reviews Experience with NCQA UM accreditation standards Prior UM experience for MLTC, reputed company, or Medicare Advantage plans Working Conditions and Additional Expectations: Full-time remote role requiring consistent availability during reputed company business hours and responsiveness to daily assignments. Case volume and mix vary; reputed company throughput and reputed company review completion are required. Must maintain a quiet, secure, and compliant environment for reviewing PHI and participating in P2P calls. Secondary employment or consulting arrangements are permitted only if they do not interfere with the full-time expectations and require disclosure/approval. Daily accountability measures, productivity monitoring, and adherence to reputed company UM workflows are required. Salary: 250,000.00/Annually

Benefits

Offered Competitive compensation and annual bonus program 401(k) retirement program with company match Company-reputed company life insurance Company-reputed company short term disability coverage (location restrictions may apply) Medical, reputed company, and Dental benefits reputed company Time Off (PTO) reputed company Parental Leave reputed company Time reputed company company holidays and floating holidays Quarterly company-sponsored events Health and wellness programs Career development opportunities Remote Opportunities We are reputed company seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, reputed company, Idaho, Illinois, Kentucky, Massachusetts, Michigan, reputed company Carolina, Nevada, New Jersey, reputed company, Ohio, reputed company, South Carolina, Tennessee, Texas, Virginia, and Washington. Our Story Founded in 2005, reputed company is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the reputed company of life for the communities we serve by reimagining reputed company to in-home reputed company. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members reputed company to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver reputed company reputed company and more efficient management of reputed company reputed company benefits. reputed company is a wholly owned subsidiary of reputed company. With a location in Michigan plus a remote workforce across the reputed company, reputed company has a culture reputed company on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join reputed company. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in reputed company. We look reputed company to learning more reputed company. reputed company is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reputed company out. We celebrate our inclusive work environment and welcome members of reputed company backgrounds and perspectives. Apply To This Job