Infotree Global Solutions
Position Overview:
The Utilization Management Medical Director plays a key role in evaluating clinical requests and ensuring that care delivery aligns with evidence-based medicine, regulatory requirements, and organizational policies. This physician leader reviews complex medical cases, collaborates with treating providers, and supports consistent, high-quality utilization decisions across inpatient and outpatient services. The role requires provides medical interpretation and determinations whether services provided by other healthcare professionals are concordant with national guidelines, CMS requirements.
Must Have: Active, unrestricted medical license in at least one U.S. jurisdiction; ability to obtain additional licenses as needed. Board Certification in an ABMS-recognized specialty.
Key Responsibilities: Review medical documentation to assess appropriateness, medical necessity, and level of care using nationally recognized clinical guidelines and payer policies. Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, or other healthcare providers Analyze complex clinical scenarios and render timely, defensible coverage determinations. Engage in peer-to-peer discussions with external physicians to obtain additional clinical details and explain determinations. Ensure all decisions meet regulatory, accreditation, and internal compliance standards. Document decisions clearly and accurately within utilization management systems. Manage daily caseload efficiently while meeting turnaround time and quality benchmarks. Participate in ongoing training and calibration activities to promote consistent decision-making. Collaborate with interdisciplinary teams to optimize workflows and improve operational performance. Stay current on evolving medical guidelines, payer policies, and utilization management best practices.
Required Qualifications: MD or DO from an accredited medical school. Minimum of 5 years of post-residency clinical practice experience; inpatient or acute care experience strongly preferred. Active, unrestricted medical license in at least one U.S. jurisdiction; ability to obtain additional licenses as needed. Board Certification in an ABMS-recognized specialty. Eligibility to pass credentialing and background verification requirements. Strong written and verbal communication skills with the ability to articulate clinical rationale clearly.
Preferred Qualifications: Prior experience in utilization management, medical review, or managed care environments. Familiarity with Medicare Advantage, Medicaid, Commercial insurance products, or value-based care models. Working knowledge of evidence-based criteria tools such as MCG®, InterQual®, or similar. Background in Internal Medicine, Family Medicine, Hospital Medicine, Emergency Medicine, or related hospital-based specialties. Experience using electronic medical record systems and utilization management platforms. Ability to adapt quickly to changing workflows, technologies, and regulatory requirements. Strong collaboration mindset with a commitment to continuous improvement and quality outcomes.
Must Have: Active, unrestricted medical license in at least one U.S. jurisdiction; ability to obtain additional licenses as needed. Board Certification in an ABMS-recognized specialty.
Key Responsibilities: Review medical documentation to assess appropriateness, medical necessity, and level of care using nationally recognized clinical guidelines and payer policies. Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and/or Commercial products, or other medical management organizations, hospitals/ Integrated Delivery Systems, health insurance, or other healthcare providers Analyze complex clinical scenarios and render timely, defensible coverage determinations. Engage in peer-to-peer discussions with external physicians to obtain additional clinical details and explain determinations. Ensure all decisions meet regulatory, accreditation, and internal compliance standards. Document decisions clearly and accurately within utilization management systems. Manage daily caseload efficiently while meeting turnaround time and quality benchmarks. Participate in ongoing training and calibration activities to promote consistent decision-making. Collaborate with interdisciplinary teams to optimize workflows and improve operational performance. Stay current on evolving medical guidelines, payer policies, and utilization management best practices.
Required Qualifications: MD or DO from an accredited medical school. Minimum of 5 years of post-residency clinical practice experience; inpatient or acute care experience strongly preferred. Active, unrestricted medical license in at least one U.S. jurisdiction; ability to obtain additional licenses as needed. Board Certification in an ABMS-recognized specialty. Eligibility to pass credentialing and background verification requirements. Strong written and verbal communication skills with the ability to articulate clinical rationale clearly.
Preferred Qualifications: Prior experience in utilization management, medical review, or managed care environments. Familiarity with Medicare Advantage, Medicaid, Commercial insurance products, or value-based care models. Working knowledge of evidence-based criteria tools such as MCG®, InterQual®, or similar. Background in Internal Medicine, Family Medicine, Hospital Medicine, Emergency Medicine, or related hospital-based specialties. Experience using electronic medical record systems and utilization management platforms. Ability to adapt quickly to changing workflows, technologies, and regulatory requirements. Strong collaboration mindset with a commitment to continuous improvement and quality outcomes.