Infotree Global Solutions
Medical Director – Utilization Management Physician
Infotree Global Solutions, New York, New York, United States
Job Summary
The Medical Director – Utilization Management provides clinical leadership and oversight for utilization management activities to ensure appropriate, high-quality, and cost-effective healthcare services. This role supports medical necessity determinations, clinical policy development, and regulatory compliance while collaborating with clinical and operational teams.
Key Responsibilities Provide physician leadership for utilization management, utilization review, and prior authorization activities. Review complex medical cases and make medical necessity determinations in accordance with clinical guidelines and regulatory requirements. Support development, implementation, and oversight of utilization management policies and procedures. Collaborate with care management, case management, and clinical operations teams to ensure appropriate care delivery. Participate in peer-to-peer reviews, appeals, and grievance resolution as needed. Ensure compliance with federal, state, and accreditation standards (e.g., MCG or InterQual). Promote evidence-based medicine and appropriate resource utilization. Provide clinical guidance and support to nursing and UM staff. Assist with quality improvement initiatives related to utilization and clinical outcomes.
Qualifications MD or DO with an active, unrestricted medical license. Board certification in a recognized specialty. Clinical experience in direct patient care. Experience with utilization management, utilization review, or managed care preferred. Knowledge of healthcare regulations, clinical guidelines, and medical necessity criteria. Strong communication and decision-making skills.
Key Responsibilities Provide physician leadership for utilization management, utilization review, and prior authorization activities. Review complex medical cases and make medical necessity determinations in accordance with clinical guidelines and regulatory requirements. Support development, implementation, and oversight of utilization management policies and procedures. Collaborate with care management, case management, and clinical operations teams to ensure appropriate care delivery. Participate in peer-to-peer reviews, appeals, and grievance resolution as needed. Ensure compliance with federal, state, and accreditation standards (e.g., MCG or InterQual). Promote evidence-based medicine and appropriate resource utilization. Provide clinical guidance and support to nursing and UM staff. Assist with quality improvement initiatives related to utilization and clinical outcomes.
Qualifications MD or DO with an active, unrestricted medical license. Board certification in a recognized specialty. Clinical experience in direct patient care. Experience with utilization management, utilization review, or managed care preferred. Knowledge of healthcare regulations, clinical guidelines, and medical necessity criteria. Strong communication and decision-making skills.