Medical Director of Utilization Management

VillageCare is a community-based, not-for-profit organization serving people with chronic care needs, as well as seniors and individuals in need of continuing care and managed care services. Our mission is to promote healing, better health and well-being to the fullest extent possible through a comprehensive array of community and residential programs, as well as managed care. VillageCare has delivered quality health care services to individuals residing within New York City for over 45 years.

About the role

The Medical Director for VillageCareMAX is a physician who serves as clinical lead for the Utilization Management Department and medical quality and cost-effectiveness activities. The Medical Director assists the VP of Medical Management to direct and coordinate medical management and quality improvement activities for the Health Plan.

Responsibilities

• Provide oversight to the delivery of utilization management (UM) services and resources, consisting of case reviews for organizational determinations, peer-to-peer reviews, and appeals.
• Utilize the care management system to document all case reviews.
• Participate in case rounds/ICT meetings in the development of UM/CM plans for individual members to ensure appropriate continuity of care.
• Analyze utilization patterns and trends, and implement strategies to bring utilization patterns in line with expected benchmarks.
• Ensure successful compliance with regulatory and contractual requirements for Medical Management functions.
• Participate in State and Federal Regulatory audits, investigations, surveys, and other reviews by the UM Department.
• Maintain current knowledge of Federal and State regulatory requirements.
• Develop and propose annual goals and provide regular reports on progress toward accomplishing those goals.

Requirements

• 3-5 years of health plan experience in medical management with Medicare and Medicaid Programs (specifically MLTC, MAP, DSNP, and MAPD).
• Experience with both inpatient and outpatient utilization management (medical, pharmacy).
• Experience with appeal reviews.
• NY Market Experience.
• No New York Group or Hospital Affiliations.

Qualifications

• Medical Doctorate is required; Master's Degree in public health is preferred.
• Current and unrestricted Physician license to practice in NY (required).
• Board Certified, preferably in internal medicine, emergency medicine, or family medicine (preferred).

Pay

$201,807.75 - $227,033.72 Annual Salary

Schedule

Full-Time

Must reside in NY/NJ/CT.