Infotree Global Solutions
Utilization Management Medical Director
Infotree Global Solutions, New York, New York, United States
Job Description:
The Utilization Management Medical Director provides clinical leadership and oversight for utilization review activities to ensure appropriate, high-quality, and cost-effective healthcare services. This role supports medical necessity determinations, promotes evidence-based practices, and ensures compliance with regulatory, accreditation, and health plan requirements. The Medical Director collaborates with clinical and operational teams to improve care outcomes and optimize resource utilization.
Key Responsibilities Provide physician leadership for utilization management programs, including prior authorization, concurrent review, retrospective review, and appeals Make medical necessity determinations using evidence-based guidelines (e.g., InterQual, MCG, CMS, NCCN) Review complex and high-risk cases, including inpatient, outpatient, behavioral health, and specialty services Participate in peer-to-peer discussions with treating providers to resolve authorization and denial issues Support denial management and oversee clinical rationale documentation in accordance with regulatory standards Ensure UM processes comply with federal, state, and accreditation requirements (CMS, NCQA, URAC) Collaborate with care management, quality, compliance, and pharmacy teams to align clinical and operational goals Contribute to development, implementation, and revision of UM policies, procedures, and clinical criteria Monitor utilization trends, identify opportunities for improvement, and support cost containment strategies Provide clinical guidance and mentorship to UM nurses and medical reviewers Participate in quality improvement initiatives and performance audits
Qualifications MD or DO degree from an accredited medical school Active, unrestricted medical license (state-specific or compact preferred) Board certification in a recognized specialty (e.g., Internal Medicine, Family Medicine, Emergency Medicine) Minimum 5–7 years of clinical practice experience Prior experience in utilization management, medical review, managed care, or health plan operations preferred
Key Responsibilities Provide physician leadership for utilization management programs, including prior authorization, concurrent review, retrospective review, and appeals Make medical necessity determinations using evidence-based guidelines (e.g., InterQual, MCG, CMS, NCCN) Review complex and high-risk cases, including inpatient, outpatient, behavioral health, and specialty services Participate in peer-to-peer discussions with treating providers to resolve authorization and denial issues Support denial management and oversee clinical rationale documentation in accordance with regulatory standards Ensure UM processes comply with federal, state, and accreditation requirements (CMS, NCQA, URAC) Collaborate with care management, quality, compliance, and pharmacy teams to align clinical and operational goals Contribute to development, implementation, and revision of UM policies, procedures, and clinical criteria Monitor utilization trends, identify opportunities for improvement, and support cost containment strategies Provide clinical guidance and mentorship to UM nurses and medical reviewers Participate in quality improvement initiatives and performance audits
Qualifications MD or DO degree from an accredited medical school Active, unrestricted medical license (state-specific or compact preferred) Board certification in a recognized specialty (e.g., Internal Medicine, Family Medicine, Emergency Medicine) Minimum 5–7 years of clinical practice experience Prior experience in utilization management, medical review, managed care, or health plan operations preferred