Medical Director - Utilization Management

This position provides clinical oversight and utilization management of Post-Acute Care (PAC) facilities and CORE services, including Home Health, Durable Medical Equipment (DME), Home Infusion Therapy, Sleep services, and more. Responsibilities include medically appropriate redirection to lower levels of care, coordination of discharges, and post-discharge follow-up to help prevent readmissions.
A key part of this role involves working strategically with Utilization Management (UM) leaders and market engagement teams to overcome facility barriers to discharge. The Medical Director will also conduct clinical conversations with facility physicians as needed to influence admissions to PAC facilities and manage PAC length of stay.
The Medical Director will perform medical necessity reviews using both industry-standard and client-specific clinical criteria for Skilled Nursing Facilities (SNF), Long-Term Acute Care Hospitals (LTACH), Inpatient Rehabilitation Facilities (IRF), and CORE services.
Additionally, the Medical Director will support hospital discharge management for up to 90 days post-discharge, providing education and high-risk member support as part of the Readmission Program.

• Conduct timely and efficient medical necessity reviews and peer-to-peer consultations, adhering to regulatory and compliance turnaround times. Issue adverse determinations when clinical criteria are not met.
• Provide clinical guidance to both licensed and non-licensed associates regarding authorization requests and the application of clinical guidelines.
• Educate the Utilization Management (UM) team on Post-Acute Care and CORE services, discharge planning, length of stay management, utilization strategies, and readmission reduction.
• Complete peer-to-peer discussions for PAC and CORE services when medical necessity criteria are not met, to support proactive discharge planning or determine when facility stays are no longer clinically appropriate.
• Participate in complex case rounds, offering clinical insight and actionable recommendations, and collaborate with multidisciplinary teams as needed.
• Support CareCentrix initiatives in Care Coordination, Utilization Management, Quality Improvement, and clinical education, as requested.
• Uphold clinical integrity in all determinations and interactions with internal and external stakeholders.
• Collaborate with health plan clinical leadership and interface with key CareCentrix leaders, including the VP of Medical Management, Lead Medical Director, Chief Medical Officer, and other executive team members.
• Partner with Market Engagement Directors and facility providers in Joint Opportunity Committee activities, as needed.
• Travel to facilities with Nurse Liaisons to observe, provide feedback, and coach CareCentrix clinical team members.
• Successfully complete and pass inter-rater reliability testing and random case audits.
• Meet or exceed Service Level Agreement (SLA) metrics and performance guarantees required by health plan clients.
• Participate in and support various committees and clinical rounds as assigned.

• MD or DO with an active and unencumbered medical license. Must have active ABIM or ABMS specialty board certification(s).
• Minimum of 5 years’ experience in an area of relevant clinical practice , and prefer at least 3 years’ experience with supporting utilization management reviews, managed care programs or care delivery networks
• Expertise in the Post-Acute Care, HH, DME and sleep fields, including current knowledge on best practices, as well as a general knowledge of requirements of regulatory and accreditation standards for payers and health care providers
• Expertise in Medicaid health plan or UM is preferred
• This position requires excellent written and verbal communication skills.
• Conveys a strong professional image, exhibits interest quality improvement, and projects a positive attitude toward all assigned work.
• Adheres to and participates in Company's mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.

• Pay Range: $250000 – $280000 / year plus corporate bonus incentive.
• Benefits: Medical, Dental, Vision, 401(k) with company match, HSA employer contributions, Dependent Care FSA employer contribution, Paid Time Off, Personal/Sick Time, Paid Parental Leave, and more.
• Award winning culture that keeps our company values at the heart of everything we do: We Care; We Do the Right Thing; We Strive for Excellence; We Think BIG; We Take our Work Seriously, Not Ourselves.

CareCentrix maintains a drug-free workplace

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.

CareCentrix accepts applications on an ongoing basis until a candidate is identified.

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