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
