Medical Director of Utilization Management

Village Care • New York, NY

1d • $201 - $227 • Hybrid

About The Position

The Medical Director for VillageCareMAX is a physician who serves as the clinical lead for the Utilization Management Department and for medical quality and cost-effectiveness activities. The Medical Director assists the VP of Medical Management in directing and coordinating medical management and quality improvement activities for the Health Plan. The role provides oversight of utilization management services and resources, including case reviews for organizational determinations, peer-to-peer reviews, and appeals.

Requirements

• Medical Doctorate.
• Current and unrestricted Physician license to practice in New York.
• 3–5 years of health plan experience in medical management with Medicare and Medicaid programs, specifically MLTC, MAP, DSNP, and MAPD.
• Experience with inpatient and outpatient utilization management, including medical and pharmacy.
• Experience with appeal reviews.
• New York market experience.
• Must reside in New York, New Jersey, or Connecticut.
• No New York group or hospital affiliations.

Nice To Haves

• Master's degree in public health.
• Board certification, preferably in internal medicine, emergency medicine, or family medicine.

Responsibilities

• Provide oversight of utilization management services and resources, including case reviews for organizational determinations, peer-to-peer reviews, and appeals.
• Document all case reviews in the care management system.
• Participate in case rounds and ICT meetings to develop UM/CM plans for individual members and support appropriate continuity of care.
• Analyze utilization patterns and trends, and implement strategies to align utilization patterns with expected benchmarks.
• Ensure successful compliance with regulatory and contractual requirements for Medical Management functions.
• Participate in State and Federal regulatory audits, investigations, surveys, and other reviews conducted by the UM Department.
• Maintain current knowledge of Federal and State regulatory requirements.
• Develop and propose annual goals and provide regular reports on progress toward accomplishing them.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree