Medical Director, Utilization Management (Commercial & MA)

Title: Medical Director, Utilization Management (Commercial & MA)Start Date: 08/10/2026 End Date: 02/10/2027 # of Openings: 1 Position Type: Contract Locations: Henderson, NV Additional Details: This is a 6-9 Month contract with a possibility of an extension. -Fully remote opportunity -Looking for an immediate start Must Have: -Utilization management experience supporting Commercial and/or Medicare Advantage populations. -Minimum of five years of clinical experience, including at least three years in utilization management, physician review, or medical leadership within a managed care or health plan setting. Description: The Medical Director, Utilization Management, plays a critical role in leading and supporting the clinical integrity of the utilization management function, with a specific focus on inpatient and post-acute care reviews. This physician leader ensures timely, consistent, and appropriate care determinations for Commercial and Medicare Advantage members based on applicable benefit plans, medical policies, clinical criteria, CMS regulations, and evidence-based practices. Reporting to the Chief Medical Officer, this role evaluates the medical necessity and appropriateness of hospital admissions, continued stays, and post-acute services. The Medical Director collaborates with utilization management and care management teams, providers, and internal stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, regulatory compliance, and the appropriate application of member benefits. What You Will Do Conduct timely utilization reviews and medical necessity determinations for inpatient admissions, continued stays, and post-acute care settings, including SNF, IRF, LTACH, and home health, for Commercial and Medicare Advantage members. Assess the appropriateness of acute and post-acute services using evidence-based guidelines, including MCG and InterQual, as well as applicable CMS criteria, Commercial medical policies, coverage guidelines, a