Medical Director of Utilization Management
About The Position
A little about us VillageCare is a community-based, not-for-profit organization serving people with chronic care needs, as well as seniors and individuals in need of continuing care and managed care services. Our mission is to promote healing, better health and well-being to the fullest extent possible. Our care is offered through a comprehensive array of community and residential programs, as well as managed care. VillageCare has delivered quality health care services to individuals residing within New York City for over 45 years Job Summary: The Medical Director for VillageCareMAX is a physician who serves as clinical lead for the Utilization Management Department and medical quality and cost effectiveness activities. The Medical Director assists the VP of Medical Management to direct and coordinate medical management and quality improvement activities for the Health Plan.
Requirements
- This position requires 3-5 years of health plan experience in medical management with Medicare and Medicaid Programs (specifically MLTC, MAP, DSNP and MAPD)
- Experience with both inpatient and outpatient utilization management (medical, pharmacy)
- Experience with appeal reviews
- NY Market Experience
- No New York Group or Hospital Affiliations
- Medical Doctorate is required for this position.
- Current and unrestricted Physician license to practice in NY
Nice To Haves
- Master's Degree in public health is also preferred
- Board Certified, preferably internal medicine, geriatrics, emergency Medicine, Family Medicine
Responsibilities
- Responsible for providing oversight to the delivery of utilization management (UM) services and resources, consisting of case reviews for organizational determinations, peer to peer reviews and appeals
- Utilizes the care management system to document all case reviews
- Participates in case rounds/ICT meetings in the development of UM/CM plans for individual members to ensure appropriate continuity of care
- Analyzes utilization patterns, trends, and implements strategies to bring utilization patterns in line with expected benchmarks
- Responsible for successful compliance with regulatory and contractual requirements for Medical Management functions
- Participates in State and Federal Regulatory audits, investigations, surveys, and other reviews by the UM Department
- Maintains current knowledge of Federal and State regulatory requirements
- Develops and proposes annual goals and provides regular reports on progress toward accomplishing those goals
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What This Job Offers
Career Level
Director
Education Level
Ph.D. or professional degree
