Medical Director

Brighton Health Plan Solutions, LLC•Levittown, NY

About The Position

The Medical Director will be responsible for providing support to commercial and worker’s compensation self-funded clients, aiming for cost-effective resolution of their member’s claims. This role involves leading and developing the team and maturing the program, fostering a culture focused on service, quality healthcare, and medical cost containment. Brighton Health Plan Solutions, with 25 years in business, is committed to improving how healthcare is accessed and delivered. The company partners with self-insured employers, Taft-Hartley Trusts, health systems, providers, and other TPAs, offering flexible and cutting-edge third-party administration services. Leveraging decades of health plan management expertise, proprietary provider networks, and an innovative technology platform, Brighton Health Plan Solutions enables clients to enhance member experience, improve health outcomes, and achieve their healthcare goals. The company encourages all team members to bring their authentic selves to work, fostering a diverse, inclusive, and belonging culture.

Requirements

Board certified with an excellent understanding of the utilization and case management process.
3 years’ experience working in a managed care environment supporting utilization management and case review with medical necessity determinations.
3 + years of prior clinical practice in either an office or hospital-based setting with boards from any of a wide range of Internal Medicine specialties so long as you are self-motivated to stay up to date on a broad range of medical services using resources such as mcg guidelines, specialty society guidelines, Up-To-Date and other resources to analyze existing cases.
Current, unrestricted clinical license(s).
Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties, in Internal Medicine or Pediatrics or a subspecialty of Internal Medicine or Pediatrics, is required for MD or DO reviewer.
Ability to communicate clearly and concisely, both verbally and in writing.
Knowledge of evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions.
Good interpersonal and communication skills to support the team approach.
Ability to work proficiently on a computer and knowledge of basic programs.

Nice To Haves

Case management and / or Population Health Management desirable.
Specialty training in addition to a first board certification highly desirable.

Responsibilities

Creates and updates medical policies and procedures in conjunction with associate medical directors and other clinical staff and assures consistency and compliance with generally accepted medical standards and guidelines.
Provides clinical support for all areas of Clinical Services.
Review medical files and make coverage and medical necessity determinations using good judgement combined with 3rd party and proprietary medical guidelines.
Identify, critique, and utilize criteria and resources such as national, state, and professional association guidelines and peer reviewed literature to support sound and objective decision making and rationales in reviews.
Advises team nurses on appropriateness of care and services through the care continuum including hospitals, skilled nursing facilities, and home care to ensure quality, cost-efficiency and continuity of care; Informs the UR Nurse of certification decisions within appropriate time frames as guided by URAC, ERISA or state regulations.
Supports training of the nurses and coordinator to improve their knowledge, independence, and understanding.
Serves as medical expert for care management and population health; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for acceptable medical care.
Reviews and resolves retro reviews, appeals and grievances related to medical quality of care and actively participates in the functioning of the plan’s grievance and appeals processes.
Along with the nurse supervisor and manager identify opportunities for improvement and collaborate to enhance team performance.
Makes appropriate outreach to community and academic based treating providers wanting to discuss cases.
Interacts telephonically and personally with employees/departments in order to maintain effective communication and support for and among departments, as well as a positive work atmosphere.
Opportunity to interact with sales and account management supporting client needs.
Collaborates with other departments i.e. Member Services, Provider Services, Claims and Contracting, to improve performance.
Attends departmental committees as assigned.
Performs other duties as required by the business.
Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job.