Emergency Medicine Physician - $200,000/yearly - $225,000/yearly

Job Description

We are seeking an experienced Medical Director of Utilization Management to provide clinical leadership within a growing health plan environment serving Medicare and Medicaid populations.

This is an outstanding opportunity for a physician who enjoys collaborating across multidisciplinary teams, driving quality outcomes, ensuring regulatory compliance, and helping members receive the right care at the right time.

What You'll Do

• Serve as the physician leader and clinical resource for Utilization Management operations.
• Conduct medical necessity reviews, peer-to-peer consultations, and appeal determinations.
• Partner with executive leadership to develop and execute medical management initiatives.
• Monitor utilization trends and identify opportunities to improve quality, efficiency, and cost-effectiveness.
• Participate in interdisciplinary care planning discussions to support coordinated member care.
• Ensure compliance with federal, state, accreditation, and contractual requirements.
• Support organizational readiness for audits, surveys, regulatory reviews, and investigations.
• Utilize care management platforms to document clinical reviews and decision-making activities.
• Evaluate utilization data and performance metrics to support strategic planning efforts.
• Contribute to annual departmental goals and provide ongoing progress updates.
• Maintain current knowledge of evolving Medicare, Medicaid, and managed care regulations.
• Collaborate with quality, care management, pharmacy, and operational teams to improve health outcomes.

Required

• Medical Doctor (MD or DO) degree, licensed in NY.
• Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or related specialty.
• 3+ years of experience in health plan medical management.
• Experience supporting Medicare and Medicaid products, including managed care populations.
• Background in utilization management across inpatient and outpatient settings.
• Experience performing appeals reviews and medical necessity determinations.
• Strong knowledge of New York healthcare market dynamics.

What Makes You Successful

• Strategic thinker with strong clinical judgment.
• Excellent communicator who can build relationships across departments.
• Data-driven leader focused on quality improvement and member outcomes.
• Strong understanding of healthcare regulations and managed care operations.
• Passion for improving access, affordability, and quality of care.