Medical Director - UM Reviewer

Medical Director - UM Reviewer (Garden City, NY) HealthCare Partners (HCP) is the largest physician‑owned and led Integrated Practice Association in the Northeast, serving the five boroughs and Long Island. The organization’s MSO and IPA together deliver quality care to 125,000 members across commercial, Medicare, and Medicaid products. HCP is seeking a Medical Director – UM Reviewer to assure appropriate and optimized health‑care delivery for members. The role will conduct medical necessity reviews (prior authorizations, concurrent, retrospective and appeals determinations), focus on healthcare cost management, quality, and member experience, and serve as a clinical expert for teams involved in concurrent review, prior authorization, case management, and strategic program development. Position Summary The Medical Director will apply evidence‑based guidelines to decision making, collaborate with senior leaders to enhance quality of care delivery, and improve outcomes and value for stakeholders. Essential Position Functions/Responsibilities Support pre‑admission review, utilization management, concurrent and retrospective review processes and case management for medical, behavioral and pharmaceutical services. Provide professional leadership and direction in utilization/cost management (UM) and clinical quality improvement (QI) of HCP, measured by benchmarked UM and QI goals. Collaborate as a clinical resource with other plan functions that interface with medical management such as provider relations, provider services, claims management, Business Intelligence, etc. Ensure members receive safe, effective, equitable, efficient, timely and patient‑centered health‑care services within their health‑plan benefits. Carry out medical policies consistent with NCQA and other regulatory bodies. Participate and/or chair clinical committees and work groups as assigned. Review medical care, medical service, and pharmacy requests against established clinical guidelines and make approval and denial determinations in accordance with evidence‑based standards, organizational policies and procedures, and regulatory requirements. Identify potentially unnecessary services and care delivery settings and recommend alternatives, as appropriate. Review appeals of medical and pharmacy denials against established clinical guidelines and make approval and denial determinations in accordance with evidence‑based standards, organizational policies and procedures, and regulatory requirements. Participate in an after‑hours telephonic on‑call rotation to provide clinical guidance and support for urgent matters outside regular business hours. Identify opportunities for corrective action plans to address issues and improve organizational performance. Collaborate with Provider Networks, Quality and Medical Management teams in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes. Participate in the retrospective review and analysis of HCP performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs, and other sources. Provide periodic written and verbal reports and updates as required in the utilization management, case management and quality management program descriptions. Assure conformance with legal and regulatory requirements; support NCQA qualification activities, including site visits and response to accrediting and regulatory agency feedback. Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, credentialing, provider orientation and profiling, etc. Conduct quality improvement and outcomes studies as directed by the state and federal regulatory agencies, and internal operating committees. Support the grievance process ensuring a fair outcome for all members. Monitor member and provider satisfaction survey results and implement changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants. May be asked to chair various HCP committees such as UM, CM, Peer Review and Credentialing. Promote wellness and ensure programs of prevention, education and outreach to members and providers consistent with the company’s Mission, Vision and Values. Perform and oversee in‑service staff training and education of professional staff. Contribute to strategic planning for existing and expanding business; recommend changes in program content in concurrence with changing markets and technologies. Participate in key marketing activities and presentations, as necessary, to assist the marketing effort. Perform other duties as assigned to support departmental and organizational goals. Qualification Requirements Skills, Knowledge, Abilities In‑depth knowledge of utilization management practices and principles in a managed care setting. Familiarity with NCQA, CMS, state Medicaid, and other regulatory guidelines. Strong analytical, organizational, and clinical decision‑making skills. Excellent communication skills (written and verbal) for peer‑to‑peer interactions and interdisciplinary collaboration. Proficiency with utilization management tools and platforms (e.g., InterQual, MCG, care management systems). Demonstrated ability to work effectively across teams and departments to support organizational goals. Understanding of value‑based care models and population health strategies. Training/Education MD or DO degree required. Board certification required (ABMS or AOA recognized specialty). Active, unrestricted license to practice medicine in the state(s) of operation (e.g., New York). No history of sanctions from state licensing boards or federal healthcare programs (e.g., Medicare, Medicaid). Experience Minimum of 5 years of clinical practice experience. Minimum of 2 years of experience in a managed care environment or utilization management role strongly preferred. Experience with reviewing medical necessity, interpreting clinical guidelines, and participating in appeal and grievance processes is highly desirable. Base Compensation: $260,000 - $285,000 Equal Employment Opportunity Statement HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non‑discrimination policy in every location where we operate. This policy applies to all aspects of employment, including but not limited to recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Job Disclaimer The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs. #J-18808-Ljbffr