Senior Utilization Review Medical Director

• Provide day-to-day clinical leadership and oversight to the Utilization Review Medical Director(s) and clinical UM team.
• Ensure consistent, accurate, and compliant application of criteria (LCDs, state Medicaid manuals, InterQual, internal policies, health plan guidelines, and evidence-based standards).
• Oversee complex clinical escalations, case consultations, and final determinations requiring senior medical judgment.
• Maintain and enforce medical review quality standards, including accuracy, documentation integrity, and compliance with NCQA UM requirements.

• Lead the development, maintenance, and revision of clinical criteria and medical policies, including DMEPOS-specific guidance.
• Ensure policies reflect current evidence, regulatory updates, clinical best practices, and contract-specific requirements.
• Partner with health plan medical leadership to align policies, resolve discrepancies, and maintain contractual compliance.
• Serve as the final approver for Integra medical policies and clinical UM guidance documents.

• Serve as the primary clinical contact for contracted health plan medical directors, CMOs, and clinical leadership.
• Lead clinical discussions, resolve escalations, align on criteria interpretations, and represent Integra in clinical presentations and governance meetings.
• Participate in health plan audits, accreditation reviews, and regulatory surveys as the clinical lead.
• Support contracting and implementation teams with clinical expertise during new implementations and renewals.

• Chair the Utilization Management Committee, ensuring compliance with regulatory and NCQA requirements, timely presentation of reports, and documentation accuracy.
• Chair the Credentialing Committee, ensuring appropriate clinical oversight of credentialing decisions, quality concerns, and adverse findings.
• Oversee preparation of committee packets, agendas, minutes, and regulatory documentation.
• Ensure decisions are evidence-based, impartial, and compliant with NCQA CR standards.

• Provide clinical leadership for NCQA UM and Credentialing standards, ensuring continuous readiness.
• Support and guide internal audits, inter-rater reliability programs, and clinical quality monitoring.
• Serve as the clinical reviewer for audit findings and contribute to corrective action plan development.
• Ensure adherence to CMS, Medicaid, state DOH, and health plan clinical documentation standards.
• Monitor clinical trends, quality signals, and provider behavior patterns; recommend improvement strategies.

• Collaborate with the SVP of Operations, UM Director, Credentialing leadership, and other internal teams to drive clinical strategy and operational improvement.
• Identify emerging clinical, regulatory, and DMEPOS industry trends and translate them into actionable strategy.
• Participate in staffing planning, training needs identification, and performance calibration for MD reviewers.
• Support development of new UM models, clinical workflows, clinical automation logic, and clinical content for technology platforms.

• MD or DO degree
• Board certification in Internal Medicine, Family Medicine, Emergency Medicine, PM&R, or another relevant specialty
• Active, unrestricted medical license
• Eligible for participation in Medicare, Medicaid, and all federally funded programs; no OIG sanctions
• 5+ years of utilization management experience, including complex case review
• Prior leadership experience overseeing clinical staff or UM operations
• Experience with NCQA UM and Credentialing accreditation standards
• Strong knowledge of Medicare, Medicaid, and DMEPOS regulatory requirements
• Exceptional written and verbal communication skills including documentation clarity

• Experience as a health plan medical director
• Experience with DMEPOS UM programs, MLTC, Medicaid, or Medicare Advantage
• Experience chairing or participating in UM, Credentialing, or clinical governance committees
• Experience developing medical policies or clinical criteria
• Experience representing an organization to external medical leadership at health plans

• Full-time remote role requiring consistent availability during standard business hours and responsiveness to daily assignments.
• Case volume and mix vary; continuous throughput and timely review completion are required.
• Must maintain a quiet, secure, and compliant environment for meeting participation, reviewing PHI and participating in P2P calls.
• Secondary employment or consulting arrangements are permitted only if they do not interfere with the full-time expectations and require disclosure/approval.
• Daily accountability measures, productivity monitoring, and adherence to all UM workflows are required.

Benefits Offered

• 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

We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Vermont, and Washington.

Our Story

Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits. Integra Partners is a wholly owned subsidiary of Point32Health.

With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.

Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.