Huntsman is hiring a Medical Director for Utilization Management. This physician will lead and support the clinical integrity of UM functions, focusing on inpatient and post-acute care reviews for Medicare Advantage members. The role ensures timely, appropriate care determinations using clinical criteria, CMS regulations, and evidence-based practices.
What You'll Do
- Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings for Medicare Advantage members.
- Assess appropriateness of acute care services using evidence-based guidelines and CMS criteria.
- Serve as the physician reviewer for escalated or complex UM cases requiring medical judgment.
- Collaborate with utilization management and care management teams to ensure consistent, clinically appropriate, and cost-effective care.
- Participate in peer-to-peer discussions with attending physicians to clarify clinical documentation.
- Identify trends in care utilization and support the development of interventions to reduce unnecessary admissions or extended stays.
- Provide input into the development and implementation of medical policy and UM protocols.
- Support CMS regulatory compliance, audit preparedness, and delegated oversight for UM functions.
- Contribute clinical expertise to quality improvement initiatives related to utilization patterns, readmission reduction, and transitions of care.
- Document all reviews and decisions according to NCQA, CMS, and organizational requirements.
- Participate in UM committee meetings and represent the health plan in external provider and stakeholder engagements as needed.
What We're Looking For
- Licensed M.D. or D.O. in good standing in the state of residence.
- Minimum of five (5) years clinical experience.
- At least three (3) years in a utilization management or medical leadership role within a managed care or health plan setting.
- Strong experience in inpatient and post-acute case review and determining medical appropriateness of acute care services.
- Knowledge of Medicare Advantage regulations and CMS coverage criteria.
- Experience with evidence-based clinical guidelines such as MCG or InterQual.
- Effective communication and negotiation skills, particularly in physician-to-physician interactions.
- Strong analytical and documentation skills.
Nice to Have
- MPH, MBA, or MHA.
- Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).
Technical Stack
- Medical management systems and software to support clinical activities in Health services.
- MS Office products.
- Evidence-based clinical guidelines (e.g., MCG, InterQual).
Team & Environment
This role reports to the Chief Medical Officer.
Work Mode
This role is a local-country work mode.
Huntsman is an equal opportunity employer.
