Medical Director of Utilization Management

Village Care•New York, NY

7d•$111 - $125•Remote

About The Position

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 Sr. Medical Director 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.
Certification: Required: Current and unrestricted Physician license to practice in NY

Nice To Haves

Master's Degree in public health is also preferred
Preferred: Board Certified, preferably internal medicine or geriatrics

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
Develops and implements critical UM strategies regarding inpatient reviews, transitions of care and out-of-network/ out-of-area coordination
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
Conducts high dollar case reviews to identify and address root case conditions and coordinate with reinsurance entity as appropriate
Collaborates with the Finance Department on Claims analysis and patterns of utilization in relation to the medical budget
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
Serves as Co-chairperson of the Credentialing Committee and participates in other Committee meetings, as assigned
Maintains current knowledge of Federal and State regulatory requirements
Develops and proposes annual goals and provides regular reports on progress toward accomplishing those goals