Medical Director

Hanover • Full-time • Remote (United States) • 5h ago

Associated Care Ventures Overview

Associated Care Ventures, Inc. (ACV) is the Birmingham-based parent company of Simpra Advantage, Inc., an Alabama-domiciled insurance company operating an Institutional Special Needs Plan, a Dual Eligible Special Needs Plan, and an Institutional Equivalent Special Needs Plan. ACV is the parent company of Alabama Select Network, LLC, which is operating an Integrated Care Network for the Alabama Medicaid Agency, to coordinate Medicare and Medicaid services state-wide for eligible individuals receiving long-term services and supports, both living at home and in nursing facilities.

Position Summary

The Medical Director, Utilization Management (UM) serves as the physician leader responsible for medical necessity determinations, utilization review activities, appeals, and clinical oversight of the health plan's medical management programs. This position provides physician leadership for inpatient, observation, post-acute, and outpatient utilization management activities to ensure high-quality, cost-effective, and evidence-based care for members.The Medical Director collaborates closely with nursing UM staff, care management, network providers, quality teams, and executive leadership to improve clinical outcomes, reduce avoidable utilization, and ensure compliance with CMS, NCQA, state, and accreditation requirements.This role is particularly responsible for building and overseeing the plan's inpatient and outpatient auth requests and observation review processes for a high-risk Special Needs Plan population.

Essential Duties and Responsibilities

Utilization Management LeadershipProvide physician oversight of all utilization management activities.
Perform medical necessity reviews for inpatient, observation, outpatient, SNF, Skill in place, and post-acute services.
Conduct Level II physician reviews and issue adverse determinations when appropriate.
Provide guidance regarding application of:
CMS regulations
Interqual Criteria
National and Local Coverage Determinations
Health plan medical policies.
Inpatient & Observation ManagementDevelop and implement inpatient and observation review programs.
Review inpatient admissions for appropriateness of level of care.
Identify opportunities to:
Reduce avoidable admissions
Reduce observation overutilization
Improve discharge planning
Prevent readmissions.
Partner with hospitals and facilities to optimize transitions of care.
Peer-to-Peer ReviewsConduct peer-to-peer discussions with treating physicians.
Participate in provider education regarding medical necessity requirements.
Resolve authorization disputes and escalation cases.
Appeals & GrievancesServe as physician reviewer for appeals and reconsiderations.
Support external review preparation.
Ensure regulatory turnaround times are met.
Clinical Program DevelopmentCollaborate with care management and quality teams to develop:
Clinical pathways
High-risk member interventions
Facility-based management programs
Utilization reduction initiatives.
Data Analytics & Performance ImprovementReview utilization trends and identify opportunities for improvement.
Analyze:

Admission rates

Observation rates

Readmissions

ER utilization

Denial rates

SNF utilization.

Participate in development of predictive models for high-risk populations.
Regulatory & Accreditation ComplianceEnsure compliance with:
CMS Medicare Advantage regulations
NCQA UM standards
State regulations
Delegation oversight requirements.
Participate in audits and regulatory examinations.
Care Program ParticipationServe as physician lead or member for:Utilization Management Committee
Quality Improvement
Readmission Reduction
Clinical Policy

Supervisory Responsibilities

Provides physician leadership and clinical oversight for:UM Nurse Managers
UM Nurses
Appeals Nurses
Clinical Pharmacists (matrix relationship)

Additional responsibilities as deemed necessary

Minimum Qualifications

Education

MD or DO degree from accredited medical school.

Licensure

Current unrestricted Alabama medical license.
Ability to obtain additional state licenses as needed.

Board Certification

Board Certified in one of the following:Internal Medicine
Family Medicine
Geriatrics
Physical Medicine & Rehabilitation
Emergency Medicine

Experience

Required:

Minimum 5 years clinical practice experience.
Minimum 3 years managed care experience.
Minimum 2 years utilization management experience.
Preferred:Medicare Advantage experience.
ISNP, DSNP, PACE, or long-term care experience.
Experience managing inpatient and observation programs.
Experience with high-risk geriatric populations.

Knowledge, Skills & Abilities

Strong understanding of Medicare Advantage regulations.
Knowledge of MCG/InterQual criteria.
Expertise in inpatient utilization management.
Knowledge of long-term care and post-acute care delivery systems.
Strong analytical skills and data interpretation.
Excellent physician communication and negotiation skills.
Ability to function effectively in a matrix organization.
Strong executive presentation skills.

Apply