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.
Scope of Role & 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.
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
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