Position Overview
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 analyses 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.
The Medical Director can be a fully remote position.
Minimum Qualifications
- Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited and approved school of medicine.
- 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
- Valid and current license to practice medicine in the state of New York.
- Board Eligible / Certification
Professional Competencies
- Integrity and Trust
- Customer Focus
- Functional / Technical Skills
- Written / Oral Communications
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