Medical Director, Utilization Management (Home Health, Acute & Post-Acute) High

HJ Staffing is seeking an experienced physician leader for a remote Medical Director, Utilization Management (Home Health, Acute & Post-Acute) role. In this position, you will serve as the primary clinical authority for home health authorization requests while supporting acute, post-acute, appeals, reconsiderations, and outpatient medical necessity reviews for Medicare Advantage populations.

Working closely with the Home Health RN Lead, UM nursing staff, and network providers, you will apply CMS regulations, National/Local Coverage Determinations (NCD/LCD), Milliman Care Guidelines (MCG), and health plan medical policies to drive evidence-based care, ensure appropriate resource utilization, and improve health outcomes.

Location: Fully Remote (Must be available during Eastern Time / EST business hours)

Employment Type: Part-Time / Contract (6-Month Contract with potential for extension)

Department: Clinical Operations / Utilization Management

What You Will Do:

Clinical Reviews & Determinations

• Evaluate outpatient referrals, inpatient direct admissions, and home health authorization requests for medical necessity.
• Review complex medical necessity denials, appeals, reconsiderations, and coverage determinations.
• Conduct peer-to-peer discussions with treating physicians and providers to discuss clinical coverage criteria, alternative care plans, and complex cases.
• Apply CMS guidelines, MCG criteria, and health plan medical policies to deliver accurate, timely coverage determinations.

Clinical Leadership & Nursing Collaboration

• Serve as the trusted physician advisor to the Home Health RN Lead and UM nursing staff, offering coaching, clinical mentoring, and complex case guidance.
• Partner with external Home Health agency leadership to promote documentation standards and alignment with evidence-based care guidelines.

Policy & Quality Improvement

• Contribute to the ongoing refinement of utilization management clinical guidelines, medical policies, and best practices.
• Collaborate with clinical operations leadership to support quality improvement initiatives and optimize care delivery through tech-enabled solutions.

What You Will Bring

• Education: MD or DO from an accredited school of medicine.
• Licensure: Active, unrestricted state medical license (MD/DO) in any U.S. jurisdiction.
• Board Certification: Board Certification in Internal Medicine, Family Medicine, Physical Medicine & Rehabilitation (PM&R), Emergency Medicine, or a closely related specialty.
• Clinical Experience: Minimum of 5+ years of direct clinical patient care experience.
• UM Experience: At least 1–2+ years of prior experience as a physician reviewer in Utilization Management, including hands-on experience reviewing medical necessity denials and appeals.
• Domain Expertise: Direct experience reviewing Home Health medical necessity, as well as acute and post-acute services under Medicare Advantage guidelines.
• Regulatory & Guidelines Command: Expert knowledge of CMS coverage criteria, NCDs/LCDs, and MCG guidelines.
• Communication & Tech Skills: Exceptional peer-to-peer communication abilities, strong multi-disciplinary leadership, and comfort navigating digital authorization workflows and EHR environments.

You Will Be Successful If You:

• Possess deep clinical expertise in home health, post-acute care, and Medicare Advantage regulations, enabling confident peer-to-peer discussions and complex medical necessity determinations.
• Act as an approachable, expert mentor to clinical nursing teams, elevating overall reviewer accuracy and case evaluation quality.
• Bring a collaborative, tech-forward, and data-driven approach to medical management.