Medical Director - Outpatient Medicare

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Medical Director - Outpatient Medicare based in the United States. This is a senior clinical leadership role focused on utilization management and medical necessity decisions for Medicare populations. You will apply your clinical expertise and professional judgment to complex cases, balancing quality of care, regulatory requirements, and appropriate resource utilization. The role involves reviewing clinical documentation and claims while applying Medicare policies, national guidelines, and evidence-based standards. You will regularly collaborate with physicians, care management teams, and other healthcare professionals to resolve complex cases and support optimal outcomes. The position also provides opportunities to contribute to appeals, quality initiatives, population health, and broader healthcare transformation efforts. This fully remote role offers flexibility while connecting you with multidisciplinary teams and regional healthcare partners. It is an opportunity to combine clinical practice experience with healthcare strategy, analytics, and value-based care in a meaningful way. Review health claims, clinical documentation, and moderately complex to highly complex clinical cases using sound medical judgment and comprehensive analysis. Determine medical necessity and make authorization decisions regarding requested services, levels of care, and sites of service. Conduct computer-based utilization reviews, with cases primarily involving inpatient and post-acute care settings, while supporting outpatient services and equipment as applicable. Evaluate clinical records against national clinical guidelines, CMS policies and determinations, clinical reference materials, internal policies, and applicable contractual requirements. Apply Medicare and Medicare Advantage requirements consistently and translate regulatory and clinical knowledge into day-to-day utilization management decisions. Prioritize daily casework and communicate determinations clearly, accurately, and within required timeframes to internal stakeholders. Conduct peer-to-peer discussions with external physicians to obtain additional information, clarify clinical circumstances, and explain or discuss authorization decisions. Apply strong professional judgment and conflict-resolution skills when addressing disputed or complex clinical determinations. Provide clinical interpretation to assess whether services align with accepted standards of care, regulatory requirements, internal policies, and applicable contracts. Participate in grievance and appeals reviews and, where applicable, support oversight of coding, clinical documentation, outpatient services, and durable medical equipment. Collaborate with care managers, case managers, regional leaders, and cross-functional teams on complex cases, quality initiatives, and population health priorities. Build productive relationships with contracted physicians, medical groups, facilities, and community partners to support value-based care and regional healthcare initiatives. Requirements: MD or DO degree from an accredited medical institution. At least 5 years of direct clinical patient-care experience following residency or fellowship , preferably including inpatient experience and/or care of Medicare-eligible populations. Current and ongoing Board Certification in an ABMS-approved medical specialty . Current, unrestricted medical license in at least one U.S. jurisdiction, with willingness to obtain additional licenses when required. Ability to meet credentialing requirements and maintain a record free of current federal or state governmental sanctions. Strong verbal and written communication skills, with a professional, responsive, and collaborative approach. Demonstrated analytical and clinical interpretation capabilities, ideally supported by experience in utilization management, quality ma