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.