Medical Director

The Medical Director can be a fully remote position

The Medical Director is responsible for assisting in ensuring appropriate health care utilization management (UM). The Medical Director serves as a physician and policy advisor to the Plan’s Chief Medical Officer.

Job Description

Assists 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 analysis 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 (Credentials, Medical Policy, others)
• Performs other duties as needed and assigned by the Chief Medical Officer relevant to utilization management, appeals, and clinical policy processes.

• Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited and approved school of medicine. (Preference for Pediatrics Doctor)
• A minimum of three years’ clinical experience
• A minimum of two years’ experience in a managed care setting, in particular utilization management
• Licensure and/or Certification Required (In NY or willing to become immediately licensed in NY)
• Valid and current license to practice medicine in the state of New York.
• Board Eligible/Certification