Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited institution
Minimum of three years' clinical experience
At least two years' experience in a managed care setting, specifically in utilization management
Valid New York State medical license and current registration
Board Certification or Board Eligible
Responsibilities
Perform Utilization Management across all lines of business, including Medicare
Conduct peer-to-peer discussions and educate physicians on policies and medical management
Assist in new technology assessments and clinical policy reviews
Perform medical necessity and appeal reviews
Supervise retrospective claims reviews to identify improvement opportunities
Analyze trends indicative of inappropriate service use or fraud
Conduct rounds with case managers as needed
Participate in departmental committees as requested
Benefits
Collaborative work environment focused on community health
Opportunity to impact healthcare delivery in New York
Engagement in continuous learning and professional development
Supportive leadership and team structure
Work-life balance with standard business hours
Full Job Description
Position Overview: Empower. Unite. Care.
MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.
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.
Work Shifts
9:00 AM- 5:00PM
Duties & Responsibilities
Performs Utilization Management for all lines of business, including Medicare. Additional UM may cover areas such as appropriate use of out-of-net 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 as requested (Credentials, Medical Policy, others)
Performs other duties as needed and assigned by the VP of Medical Director relevant to utilization management, appeals, and clinical policy processes.
Minimum Qualifications
Required Education, Training & Professional Experience:
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 New York State license and current registration to practice medicine in the state of New York.
Board Certification Board Eligible/Certification
Professional Competencies:
Integrity and Trust
Customer Focus
Functional/Technical Skills
Written/Oral Communications
About NYC Health + Hospitals
NYC Health + Hospitals is a healthcare system that provides medical care to residents of New York City. The system was founded in 1969 and is headquartered in New York, New York. NYC Health + Hospitals has a network of hospitals, clinics, and other healthcare facilities throughout the city. The system provides a wide range of medical services, including primary care, specialty care, and emergency care. NYC Health + Hospitals is committed to providing high-quality, affordable healthcare to all New Yorkers, regardless of their ability to pay.
