Medical Director

MetroPlusHealth 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, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The 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 Plan's Chief Medical Officer.

Job Description

• Performs Utilization Management related to inpatient level of care and home care services. Additional UM may cover other areas such as appropriate use of out of network providers.
• Conducts peer to peer discussions, as applicable, and educates physicians (in-network and out-of-network) and others on current policies and medical management issues.
• Assists in new technology assessment and clinical policy review, as required, and facilitates researching the evidence-based literature.
• Performs medical necessity and appeal reviews
• Supervises retrospective review of claims to identify practice patterns that could be improved to reduce costs and improve care
• Conducts analyses to identify trends and patterns suggestive or indicative of inappropriate or excessive use of services or equipment (fraud, waste, and abuse)
• Conducts rounds with case managers as needed
• Participates in department committees (Credentials, Medical Policy, others)
• Performs other duties as needed and assigned by the Chief Medical Officer relevant to utilization management, appeals, and clinical policy processes. The Medical Director can be a fully remote position.

Minimum Qualifications

• Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited and approved school of medicine.
• A minimum of three years' clinical experience
• A minimum of two years' experience in a managed care setting, in particular utilization management

Licensure and/or Certification Required

• Valid and current license to practice medicine in the state of New York.
• Board Eligible/Certification

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Written/Oral Communications

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