Infotree Global Solutions
Utilization Medical Director - Physician
Infotree Global Solutions, New York, New York, United States
Position Summary
The Medical Director for Utilization Management (UM) provides clinical leadership and oversight for medical necessity determinations, utilization review activities, and care management programs across Medicare, Medicaid, and Commercial health plans. This role ensures appropriate, cost-effective, and evidence-based healthcare delivery through the application of nationally recognized clinical guidelines, including MCG and/or InterQual, while maintaining compliance with federal, state, and accreditation requirements.
Key Responsibilities Provide physician-level medical review and determination for prospective, concurrent, and retrospective utilization reviews Apply MCG and/or InterQual criteria to assess medical necessity for inpatient, outpatient, and post-acute services Conduct peer-to-peer reviews with treating providers to resolve authorization and denial issues Ensure consistency, fairness, and clinical accuracy in coverage determinations Support development, implementation, and refinement of UM policies and procedures Collaborate with Care Management, Quality, Appeals, and Compliance teams Ensure compliance with CMS, Medicare Advantage, Medicaid, NCQA, URAC, and state regulatory requirements
Qualifications Education & Licensure MD or DO degree from an accredited medical school Active, unrestricted medical license (state-specific or compact, as required) Board Certification (e.g., Internal Medicine, Family Medicine, Emergency Medicine, or specialty relevant to population served) Experience 5+ years of clinical practice experience 3+ years of Utilization Management or Health Plan Medical Director experience preferred Direct experience with Medicare and/or Medicaid strongly preferred Experience in Commercial insurance utilization review Strong working knowledge of MCG and/or InterQual guidelines Familiarity with CMS regulations, Medicare Advantage, Medicaid managed care Strong communication skills for provider peer-to-peer discussions
Key Responsibilities Provide physician-level medical review and determination for prospective, concurrent, and retrospective utilization reviews Apply MCG and/or InterQual criteria to assess medical necessity for inpatient, outpatient, and post-acute services Conduct peer-to-peer reviews with treating providers to resolve authorization and denial issues Ensure consistency, fairness, and clinical accuracy in coverage determinations Support development, implementation, and refinement of UM policies and procedures Collaborate with Care Management, Quality, Appeals, and Compliance teams Ensure compliance with CMS, Medicare Advantage, Medicaid, NCQA, URAC, and state regulatory requirements
Qualifications Education & Licensure MD or DO degree from an accredited medical school Active, unrestricted medical license (state-specific or compact, as required) Board Certification (e.g., Internal Medicine, Family Medicine, Emergency Medicine, or specialty relevant to population served) Experience 5+ years of clinical practice experience 3+ years of Utilization Management or Health Plan Medical Director experience preferred Direct experience with Medicare and/or Medicaid strongly preferred Experience in Commercial insurance utilization review Strong working knowledge of MCG and/or InterQual guidelines Familiarity with CMS regulations, Medicare Advantage, Medicaid managed care Strong communication skills for provider peer-to-peer discussions