A New York City-based health services system is seeking a licensed professional to join their staff Remotely as their new Medical Director - Utilization Management.
About the Opportunity:
- Shift: Day
- Schedule: Monday to Friday
- Hours: Standard business
- Setting: Remote
Responsibilities:
- Perform utilization management across all lines of business, including Medicare.
- Conduct peer-to-peer discussions and educate physicians on policies and medical management issues.
- Support new technology assessment and clinical policy review through evidence-based research.
- Review medical necessity and appeal cases.
- Analyze utilization patterns, retrospective claims, and potential fraud, waste, and abuse indicators.
Qualifications:
- Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited and approved School of Medicine
- Minimum of 3 years of Clinical experience
- Minimum of 2 years of experience in a Managed Care setting, particularly Utilization Management
- Valid New York State medical license and current registration to practice medicine in New York
- Board certification or board eligibility
Desired Skills:
- Experience conducting case manager rounds.
- Experience participating in medical policy, credentials, or similar committees
- Exposure to out-of-network provider utilization management
