Medical Director - UM Reviewer (Part-Time)

About the role

HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities.

Responsibilities

• Conduct medical necessity reviews including prior authorizations, concurrent reviews, retrospective reviews, and appeals determinations.
• Apply evidence-based guidelines to decision making and collaborate with senior leaders to enhance quality of care delivery, improve outcomes, and increase value delivered to stakeholders.
• Serve as a clinical resource to teams dedicated to concurrent review, prior authorization, case management and strategic program development.
• Provide professional leadership and direction in utilization/cost management (UM) and clinical quality improvement (QI) as measured by benchmarked UM and QI goals.
• Work collaboratively with provider relations, provider services, claims management, Business Intelligence, and other plan functions that interface with medical management.
• 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.
• 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 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 satisfactory relationships 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 the development of 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.

Qualifications

• 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).

Skills

• 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.

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.

Pay

Base Compensation: $260,000 – $285,000 annually

Bonus Incentive: Eligibility based off organizational performance

Benefits

• Fully paid Medical & Dental employee coverage
• Robust benefits package including PTO, 401k, FSA, Tuition Reimbursement, etc.