Vice President of Medical Directors - Health Plan Experience

Scope Of Role & Responsibilities

• Reviews cases, determines medical necessity, and consults with physicians to review length of stay and reimbursement documentation.
• Serves as a resource for the Utilization Management (UM) department staff and nurse Care Managers on concurrent review and preauthorization referrals.
• Ensures that members receive appropriate services consistent with their benefits, regulatory requirements, and established clinical criteria.
• Works with the VP of Clinical Services to oversee day-to-day UM operations.
• Provides clinical support for members and provider appeals.
• Builds a health informatics function and ensures decisions are made according to data insights.
• Affirms new technology assessments and clinical policy reviews as required.
• Responsible for implementing ongoing changes in policy and procedures from state and government entities.
• Participates in the development of strategic planning for existing and expanding business.
• Represents the health plan at regulatory meetings held by the New York State Department of Health, the New York City Department of Health and Mental Hygiene, and managed care trade organizational meetings as necessary.

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 post-residency.
• A minimum of five years’ experience in a managed care setting with at least 3 years specifically overseeing Utilization Management.
• Proven experience with health informatics/data sciences and regulatory compliance.
• Experience with NYS regulations and compliance is strongly preferred.