Medical Director - Health Plan

Scope Of Role & Responsibilities

• Performs Utilization Management for all lines of business, including Medicare.
• 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.
• Affords assistance 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 as requested (Credentials, Medical Policy, others).
• Performs other duties as needed and assigned by the VP of Medical Director relevant to utilization management, appeals, and clinical policy processes.

Required Education, Training & Professional Experience

• 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.

Licenses & Certifications

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

Professional Competencies

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