Position: Medical Director of Utilization Management
Location: 120 Broadway New York (Must Reside in NY/NJ/CT)
Work Schedule: Full-TimeCompensation: $201,807.75 - $227,033.72 Annual Salary
Job Summary: The Medical Director for VillageCareMAX is a physician who serves as clinical lead for the Utilization Management Department and medical quality and cost effectiveness activities. The Medical Director assists the VP of Medical Management to direct and coordinate medical management and quality improvement activities for the Health Plan.
Essential Job Functions: - Responsible for providing oversight to the delivery of utilization management (UM) services and resources, consisting of case reviews for organizational determinations, peer to peer reviews and appeals
- Utilizes the care management system to document all case reviews
- Participates in case rounds/ICT meetings in the development of UM/CM plans for individual members to ensure appropriate continuity of care
- Analyzes utilization patterns, trends, and implements strategies to bring utilization patterns in line with expected benchmarks
- Responsible for successful compliance with regulatory and contractual requirements for Medical Management functions
- Participates in State and Federal Regulatory audits, investigations, surveys, and other reviews by the UM Department
- Maintains current knowledge of Federal and State regulatory requirements
- Develops and proposes annual goals and provides regular reports on progress toward accomplishing those goals
Experience: - This position requires 3-5 years of health plan experience in medical management with Medicare and Medicaid Programs (specifically MLTC, MAP, DSNP and MAPD)
- Experience with both inpatient and outpatient utilization management (medical, pharmacy)
- Experience with appeal reviews
- NY Market Experience
- No New York Group or Hospital Affiliations
Education and certification: - Medical Doctorate is required for this position.
- Master's Degree in public health is also preferred
- Certification: Required: Current and unrestricted Physician license to practice in NY
- Preferred: Board Certified, preferably internal medicine or emergency medicine or family medicine
