Medical Director (Utilization Management)  na Bickham Services Unlimited, LLC

Job Location: NV - Henderson, 89074 

Job 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 and 
appropriate care determinations for Medicare Advantage members, guided by clinical 
criteria, CMS regulations, and evidence-based practices. 
Reporting to the Chief Medical Officer, this role focuses on evaluating medical necessity 
and appropriateness of hospital admissions, continued stays, and post-acute services. 
The Medical Director collaborates with care management teams, providers, and internal 
stakeholders to ensure care decisions support optimal outcomes, cost-efficiency, and 
regulatory compliance. 

What You Will Do:

• Conduct timely utilization review and medical necessity determinations for
 inpatient admissions, continued stays, and post-acute care settings (e.g., SNF, IRF,
 LTACH, home health) for Medicare Advantage members
 • Assess appropriateness of acute care services using evidence-based guidelines
 (e.g., MCG, InterQual) 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 and support appropriate levels of care 
• 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 

You Will Be Successful If: 
• Extensive knowledge of the use of MCG guidelines in clinical decision making. 
• Knowledge of medical management systems and software to support clinical 
actives in Health services. 
• Experience in population health management and use of data to design and 
implement clinical programs. 
• Experience working with different levels of staff in a matrix organization. 
• Strong analytical, problem-solving skills with good negotiation skills. 
• Very strong interpersonal skills, including the ability to establish and maintain 
effective working relationships with individuals at all levels both inside and outside 
of the organization. 
• Effective oral and written communication skills, including the ability to effectively 
explain complex information and documents according to clinical standards. 
• Demonstrated ability to commit to and facilitate an atmosphere of collaboration 
and teamwork. 
• Ability to supervise and mentor staff, analyze situations independently and make 
appropriate decisions. 
• Ability to prepare written reports and maintain accurate records in compliance with 
State and federal requirements for clinical documentation and privacy rules. 
• Strong analytical, assessment and problem-solving skills with intermediate 
negotiation skills. 
• Very strong interpersonal skills, including the ability to establish and maintain 
effective working relationships with individuals at all levels both inside and outside 
of the organization. 
• Advanced computer skills that include MS Office products. 
• Demonstrate ability to respect and maintain the confidentiality of all sensitive 
documents, records, discussions, and other information generated in connection 
with activities conducted in, or related to, patient healthcare, business or employee 
information and make no disclosure of such information except as required in the 
conduct of business. 
• Strong attention to detail; work accurately and at a reasonable rate of speed. 

What You Will Bring: 
• Licensed M.D. or D.O. in good standing in the state of residence. 
• Minimum of five (5) years clinical experience, with 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 
• Preferred: MPH, MBA, or MHA; Certification by the American Board of Quality 
Assurance and Utilization Review Physicians (ABQAURP) 
Additional Details: 
This is a temp to perm opportunity. Candidate must NOT require sponsorship now, or in the 
future.