Mosaic Health
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Overview
The Utilization Management (UM) Medical Director provides clinical leadership for the UM program, ensuring members receive appropriate, high-quality care. You will oversee review guidelines, collaborate with internal teams and external partners, and drive compliance with regulatory and accreditation standards. Key Responsibilities
Lead the development, implementation, and periodic review of UM policies and clinical criteria Provide physician oversight for concurrent and retrospective review activities Approve and interpret clinical guidelines, pathways, and criteria for admission, continued stay, and discharge Serve as the primary clinical liaison with payers, providers, and regulatory bodies Mentor and educate UM nurses, physician reviewers, and other staff on best practices Analyze utilization data and quality metrics to identify trends and areas for improvement Participate in appeals and peer-to-peer discussions to resolve clinical disputes Maintain compliance with NCQA, URAC, CMS, state regulations, and organizational standards Qualifications
Medical degree (MD or DO) from an accredited institution Active, unrestricted medical license in the applicable state/region Board certification in an acute-care specialty (e.g., Internal Medicine, Family Medicine, Pediatrics) Minimum of 5 years clinical practice experience, with 2+ years in utilization management or managed care Compensation: $263,488 - $329,360 and bonus eligible Seniority level
Director Employment type
Full-time Job function
Health Care Provider Industries: Hospitals and Health Care
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The Utilization Management (UM) Medical Director provides clinical leadership for the UM program, ensuring members receive appropriate, high-quality care. You will oversee review guidelines, collaborate with internal teams and external partners, and drive compliance with regulatory and accreditation standards. Key Responsibilities
Lead the development, implementation, and periodic review of UM policies and clinical criteria Provide physician oversight for concurrent and retrospective review activities Approve and interpret clinical guidelines, pathways, and criteria for admission, continued stay, and discharge Serve as the primary clinical liaison with payers, providers, and regulatory bodies Mentor and educate UM nurses, physician reviewers, and other staff on best practices Analyze utilization data and quality metrics to identify trends and areas for improvement Participate in appeals and peer-to-peer discussions to resolve clinical disputes Maintain compliance with NCQA, URAC, CMS, state regulations, and organizational standards Qualifications
Medical degree (MD or DO) from an accredited institution Active, unrestricted medical license in the applicable state/region Board certification in an acute-care specialty (e.g., Internal Medicine, Family Medicine, Pediatrics) Minimum of 5 years clinical practice experience, with 2+ years in utilization management or managed care Compensation: $263,488 - $329,360 and bonus eligible Seniority level
Director Employment type
Full-time Job function
Health Care Provider Industries: Hospitals and Health Care
#J-18808-Ljbffr