Medical Director - Health Plan

Job Description

Job Description

Position Overview:

MetroPlus Health is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

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.

Scope of Role & Responsibilities:

• Performs Utilization Management for all lines of business, including Medicare. Additional UM may cover areas such as appropriate use of out-of-net network providers.
• Conducts peer to peer discussions, as applicable, and educates physicians (in-network and out-of-network) and others on current policies and medical management issues.
• 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 analyses 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 as requested (Credentials, Medical Policy, others)
• Performs other duties as needed and assigned by the VP of Medical Director relevant to utilization management, appeals, and clinical policy processes.

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
• A minimum of two years’ experience in a managed care setting, in particular utilization management

Licensure and/or Certification Required:

• Valid New York State license and current registration to practice medicine in the state of New York.
• Board Certification Board Eligible/Certification

Professional Competencies:

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Written/Oral Communications

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