Medical Director, Utilization Management

Medical Director, Utilization Management

Location: New Jersey – Fully Remote Work Arrangement: Remote Job Type: Contract Contract Length: 6–9 months, with potential for extension Schedule: Standard business hours; schedule to be determined with the client Start Date: Immediate / ASAP Department: Healthcare – Utilization Management (Clinical) Reports To: Chief Medical Officer Openings: 1 Pay: Hourly, DOE

About the Position

Bickham Services Unlimited, LLC is seeking a Medical Director, Utilization Management to support a healthcare utilization management program client serving members.

The Medical Director will lead and support clinical utilization management activities, with a primary focus on inpatient and post-acute care reviews. This position is responsible for ensuring timely, consistent, and appropriate medical necessity determinations based on member benefit plans, medical policies, clinical criteria, CMS regulations, and evidence-based practices.

Key Responsibilities

• Conduct timely utilization reviews and medical necessity determinations for inpatient admissions and continued stays.
• Review post-acute care services, including SNF, IRF, LTACH, and home health .
• Evaluate the appropriateness of acute and post-acute services using MCG, InterQual, CMS criteria, commercial medical policies, and member benefit plans .
• Apply applicable regulatory and coverage standards based on the member's line of business.
• Serve as a physician reviewer for escalated, complex, or potentially adverse utilization management cases.
• Participate in peer-to-peer discussions with treating and attending physicians.
• Collaborate with utilization management and care management teams to support consistent and cost-effective care.
• Identify utilization trends and support initiatives designed to reduce avoidable admissions and readmissions.
• Provide clinical input regarding medical policies, clinical guidelines, and utilization management protocols.
• Support regulatory compliance, audit readiness, accreditation, and delegated oversight activities.
• Contribute to quality improvement initiatives involving utilization patterns, readmissions, and care transitions.
• Ensure reviews and determinations are appropriately documented in accordance with CMS, NCQA, and applicable state and federal requirements.
• Participate in utilization management committee meetings and represent the health plan externally when needed.

Minimum Qualifications

• Active, unrestricted M.D. or D.O. license in good standing.

• Current board certification in an appropriate medical specialty.

• At least 5 years of clinical experience , including at least 3 years of experience in utilization management, physician review, or medical leadership within a managed care or health plan environment.

• Physician-level utilization management experience.

• Strong experience with inpatient and post-acute care reviews and medical necessity determinations.

• Knowledge of commercial benefits, coverage requirements, and medical policies.

• Experience applying MCG and/or InterQual guidelines .

• Experience conducting peer-to-peer discussions and communicating complex or adverse determinations.

• Candidate must reside in or hold applicable licensure for New Jersey .

Preferred Qualifications

• Master's degree such as MPH, MBA, or MHA .
• ABQAURP certification.
• Experience with quality improvement, regulatory compliance, accreditation, or delegated oversight.