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

Medical Director, Utilization Management (Home Health, Acute & Post-Acute)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 ManagementWhat You Will Do:Clinical Reviews & DeterminationsEvaluate 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 CollaborationServe 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 ImprovementContribute 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 BringEducation: 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.