Dir Medical Reviews

HF Management Services•New York City, NY

About The Position

The Director, Medical Reviews position is responsible for conducting medical necessity reviews in the context of utilization management and appeals and managing the development and implementation of quality improvement initiatives. Duties & Responsibilities: The Medical Director will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations. The Medical Director will render determinations in the format and within timeframes to follow Regulatory and Operational policies. The Medical Director will: Maintain productivity standards. Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses Design reports, analyze trends and establish policies to ensure operation of a high quality, efficient program Attend meetings in place of other Executive and Sr. Medical Directors Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed Complete mandatory Company compliance training and training in new systems and software. Participate in Peer-to-Peer discussions with provider organizations upon request Perform other duties as assigned Provide weekend coverage as needed Responsibilities may be adjusted based on changing needs of the organization. This position does not involve direct patient care.

Requirements

Licensed M.D. or D.O.
Board Certified in a specialty recognized by the American Board of Medical Specialties
Time management, critical thinking, communication, and critical thinking skills
Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
Knowledge of member satisfaction/incident management and regulations
Knowledge of quality improvement methodologies
5 years clinical experience
NYS Licensed M.D, D.O. (Unrestricted NYS active license)

Nice To Haves

Board Certified in Internal Medicine, Family Practice, OBGYN or Emergency Medicine
Previous, relevant experience in utilization management and clinical practice
Knowledge of Medicare, Medicaid, and MLTC plans

Responsibilities

Assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations.
Render determinations in the format and within timeframes to follow Regulatory and Operational policies.
Maintain productivity standards.
Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses
Design reports, analyze trends and establish policies to ensure operation of a high quality, efficient program
Attend meetings in place of other Executive and Sr. Medical Directors
Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed
Complete mandatory Company compliance training and training in new systems and software.
Participate in Peer-to-Peer discussions with provider organizations upon request
Perform other duties as assigned
Provide weekend coverage as needed
Ensures compliance to internal Healthfirst and external regulations.
Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
Annual Inter-Rater Reliability (IRR) Testing
Complies with the Healthfirst Conflict of Interest Policy for Professionals