The Medical Director will conduct medical necessity determinations for inpatient and post-acute care while ensuring compliance with CMS and NCQA standards. They will also lead peer-to-peer discussions and collaborate with care management teams to optimize clinical outcomes and utilization trends.
The Medical Director will serve as the primary clinical authority for home health authorization requests and support medical necessity reviews for Medicare Advantage populations. They will also provide clinical leadership, mentor nursing staff, and collaborate with providers to ensure evidence-based care and regulatory compliance.
Conduct peer-to-peer discussions with treating providers and review clinical documentation to assess medical necessity and appropriate levels of care using CMS requirements, approved criteria, and health plan policies. Document determinations, collaborate collegially with providers, escalate complex cases, lead clinical review discussions, and identify recurring trends for utilization management leadership.
