Utilization Review Medical Director

Summary

Join Integra Partners as a full-time Utilization Review Medical Director and conduct timely clinical reviews of Durable Medical Equipment (DME) requests, adhering to Medicare/Medicaid guidelines and health plan criteria. You will function within a daily review queue, evaluating clinical documentation and rendering determinations based on applicable criteria. Collaboration with the utilization management team, participation in Peer-to-Peer discussions with providers, and maintaining accurate documentation are key responsibilities. This remote position requires strong clinical knowledge, excellent communication skills, and experience with UM activities for Medicare Advantage Plans. The role demands daily accountability, adherence to timelines, and reliable internet connectivity. Integra Partners offers competitive compensation, including an annual bonus program and comprehensive benefits.

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
• 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
• 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

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

Preferred Qualifications

• Familiarity with electronic UM systems and queue-based case management preferred
• Experience performing UM activities for MLTC, Medicaid and/or Medicare Advantage Plans preferred
• DMEPOS experience preferred

Benefits

• Competitive compensation and annual bonus program
• 401(k) retirement program with company match
• Company-paid life insurance
• Company-paid short term disability coverage (location restrictions may apply)
• Medical, Vision, and Dental benefits
• Paid Time Off (PTO)
• Paid Parental Leave
• Sick Time
• Paid company holidays and floating holidays
• Quarterly company-sponsored events
• Health and wellness programs
• Career development opportunities
• Remote Opportunities