Medical Director

The Medical Director can be a fully remote position

The Medical Director is responsible for assisting in ensuring appropriate health care utilization management (UM). The Medical Director serves as a physician and policy advisor to the Plan’s Chief Medical Officer.

Job Description

Performs Utilization Management related to inpatient level of care and home care services. Additional UM may cover other areas such as appropriate use of out of network providers. Conducts peer to peer discussions, as applicable, and educates physicians (in-network and out-of-network) and others on current policies and medical management issues. Assists in new technology assessment and clinical policy review, as required, and facilitates researching the evidence–based literature.

• Performs medical necessity and appeal reviews
• Supervises retrospective review of claims to identify practice patterns that could be improved to reduce costs and improve care
• Conducts analysis to identify trends and patterns suggestive or indicative of inappropriate or excessive use of services or equipment (fraud, waste, and abuse)
• Conducts rounds with case managers as needed
• Participates in department committees (Credentials, Medical Policy, others)
• Performs other duties as needed and assigned by the Chief Medical Officer relevant to utilization management, appeals, and clinical policy processes.

Requirements

• Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited and approved school of medicine. (Preference for Pediatrics Doctor)
• A minimum of three years’ clinical experience
• A minimum of two years’ experience in a managed care setting, in particular utilization management
• Licensure and/or Certification Required (In NY or willing to become immediately licensed in NY)
• Valid and current license to practice medicine in the state of New York.
• Board Eligible/Certification