Mirrai Careers

Medical Director, Utilization Management

Bickham Services Unlimited, LLC

Contract Posted 10d ago
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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.

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