Utilization Review Medical Director (Contract)

The Utilization Review Medical Director is responsible for conducting clinical reviews of Durable Medical Equipment (DME) and related requests to support Integra’s Utilization Management (UM) operations. Role functions within a structured, high-volume authorization review queue and requires adherence to workflow timelines, clinical accuracy standards, and productivity expectations. The Medical Director ensures determinations are made in accordance with Medicare and Medicaid guidelines, health plan–specific criteria, internal policies, and regulatory requirements. This role is best suited for physicians who thrive in a process-driven environment and are committed to consistency, compliance, and evidence-based decision making.

The Utilization Review Medical Director’s responsibilities include but are not limited to:* Conduct timely clinical reviews of DMEPOS authorization requests using applicable criteria, including LCDs, Medicaid Manuals, InterQual, MCG, internal medical policies, and health plan requirements. * Function within a real-time review queue and maintain continuous case throughput in alignment with organizational turnaround and productivity standards. * Evaluate clinical documentation, identify missing elements, and render determinations supported by clear clinical rationale. * Review cases escalated by UM staff and/or UM Leadership when criteria do not apply to the enrollee’s unique clinical situation or when clinical judgment is required. * When appropriate, consult with external board-certified reviewers, engage with ordering practitioners, or conduct additional clinical dialogue prior to rendering a determination. * Participate in Peer-to-Peer (P2P) discussions, including maintaining availability for scheduled appointment times. * Document all clinical decisions clearly, concisely, and consistently in accordance with internal SOPs, NCQA standards, and regulatory expectations. * Maintain inter-rater reliability and participate in