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Medical Director - Utilization Management

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Metroplus Health PlanNew York, NY
$200 - $250 Full-time
  • About NYC Health + HospitalsMetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.
  • As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus network includes over 27,000 primary care providers, specialists and participating clinics.
  • For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
  • Position OverviewThe 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 Plans Chief Medical Officer.
  • Performs Peer to Peer discussions, as applicable, and educates physicians and others on current policy, medical management issues.
  • Assist the Chief Medical Officer in the identification and implementation of opportunities for improving the pre and post payment review process.
  • Assist in new technology assessment and clinical policy review as required and has facility in researching the evidence based literature, including use of comparable database.
  • Perform other duties as needed and assigned by the Chief Medical Officer relevant to UM,Appeals and clinical policy process.
  • A minimum of three years clinical experienceA minimum of two years experience in a managed care setting, in particular utilization managementLicensure and/or Certification RequiredValid and current license to practice medicine in the state of New York. Board Eligible/CertificationProfessional CompetenciesIntegrity and TrustCustomer FocusFunctional/Technical SkillsWritten/Oral Communications

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