Utilization Review Medical Director

Position Summary

Integra Partners is seeking a full-time Utilization Review Medical Director to support our Utilization Management team. This is a salaried, 40+ hour per week position expected to be your primary professional responsibility. The role requires daily participation in a structured authorization review queue and close adherence to workflow timelines and productivity standards.

This role is best suited for candidates who are focused, responsive, and comfortable working in a high-volume, process-driven environment with a strong commitment to clinical accuracy, compliance, and consistency.

Job Responsibilities:

Conducting timely clinical review of Durable Medical Equipment (DME) requests in alignment with Medicare/Medicaid guidelines, state-specific, and health plan criteria.

Function within a daily review queue, processing cases throughout the day as part of routine operations.

Evaluate clinical documentation provided and render determinations based on applicable criteria (i.e. LCD, InterQual, NY Medicaid Manual, Internal policies, member handbooks)

Upon an enrollee’s individual situation or the local delivery system rendering the criteria inappropriate, the Utilization Management Nurse will route the case to the UR Medical Director. The UR Medical Director will review the case and may consult with board certified external reviewers and/or discuss the case with the ordering practitioner before rendering a determination.

Participate in Peer to Peer (P2P) appointments for live discussions with requesting and servicing providers, including being available at appointment times

Maintain clear, complete, and accurate documentation of all reviews and clinical decisions in alignment with internal SOPs and regulatory expectations.

Adhere to health plan inter-rater reliability standards and participate in periodic review calibration

Serve as a clinical resource and subject matter expert for the utilization management team.

Requirements:

MD or DO Required

Board-certified in Internal Medicine, Family Medicine or Physical Medicine & Rehabilitation

No current or past OIG or state sanctions; eligible for participation in Medicare, Medicaid, and other federally funded programs.

Experience with NCQA accreditation

Excellent written and verbal communication skills, with strong attention to documentation accuracy

Professionalism and responsiveness in handling requests

Familiarity with electronic UM systems and queue-based case management preferred

Analytical ability and clinical knowledge to identify trends and report findings

Interpersonal skills necessary to develop and maintain a wide variety of cooperative working relationships

Experience performing UM activities for MLTC, Medicaid and/or Medicare Advantage Plans preferred

DMEPOS experience preferred

Working Conditions and Additional Expectations:

This is a remote full-time position, but requires consistent availability during standard business hours and responsiveness to daily work assignments

The role is structured around a real-time, case-by-case review queue. Review volume and case mix may vary but continuous throughput is expected

Candidate must have reliable internet connectivity and a quiet, secure environment for handling PHI and confidential materials.

This is not a per diem or part-time review role

Secondary employment or consulting arrangements that interfere with the full-time expectations of this role are not permitted.

Role requires daily accountability, productivity monitoring, and adherence to workflow timelines

Salary: $250,000.00/annual