Medical Director - Utilization ManagementLocation: Hybrid - New York, NY 10005 (Must reside in NY, NJ, or CT)
Schedule: Monday-Friday | 9:00 AM - 5:00 PM
Work Model: Hybrid (2 days onsite per week)
Compensation: $210,000- $227,033 annually Position Overview We are seeking an experienced
Medical Director of Utilization Management to provide clinical leadership for a growing managed care organization. This physician leader will oversee utilization management operations, medical necessity determinations, quality improvement initiatives, regulatory compliance, and interdisciplinary collaboration to ensure high-quality, cost-effective care for members.
Key Responsibilities - Provide clinical oversight for utilization management, including medical necessity determinations, complex case reviews, peer-to-peer consultations, and appeals.
- Document clinical reviews and determinations within the organization's care management platform.
- Collaborate with interdisciplinary care teams to develop comprehensive utilization and care management plans.
- Analyze utilization trends and implement strategies to improve quality, efficiency, and resource utilization.
- Ensure compliance with all state, federal, and contractual medical management requirements.
- Lead preparation for regulatory audits, investigations, surveys, and external reviews.
- Stay current on evolving healthcare regulations affecting Medicare and Medicaid programs.
- Develop annual departmental goals and provide leadership with regular performance updates.
Qualifications Required - MD or DO with an unrestricted New York medical license.
- 3-5 years of Medical Management experience within a health plan.
- Extensive experience with Medicare and Medicaid programs, including:
- Experience with both inpatient and outpatient utilization management.
- Strong background in medical necessity reviews, appeals, and peer-to-peer consultations.
- Knowledge of pharmacy utilization management and formulary considerations.
- Familiarity with the New York managed care market and regulatory environment.
- No active New York hospital or group practice affiliations.
Preferred - Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine.
- Master's degree in Public Health (MPH), Healthcare Administration (MHA), or related field.
- Experience participating in state and federal regulatory audits.
- Proficiency with enterprise care management and electronic health record (EHR) systems.
- Experience developing population health, preventive care, or disease management initiatives.
Why Consider This Opportunity? - Executive-level physician leadership role within managed care.
- Opportunity to shape utilization management strategy and quality initiatives.
- Hybrid work schedule with only two days onsite each week.
- Collaborative leadership environment focused on improving healthcare outcomes.
