Medical Director - UM Reviewer at HealthCare Partners, MSO Garden City, NY

Medical Director - UM Reviewer

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. Our MSO employs 200+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources. 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. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care.

Position Summary

The Medical Director will be responsible for assuring appropriate and optimized health care delivery for members. The Medical Director will be primarily responsible for conducting medical necessity reviews, including prior authorizations, concurrent reviews, retrospective reviews, and appeals determinations. The role will focus on efforts to achieve excellence in healthcare cost management, quality, member experience, and improved population and member outcomes. They will serve as a clinical expert for teams dedicated to concurrent review, prior authorization, case management and strategic program development and implementation. The Medical Director will serve as a resource for our IPA physicians. The Medical Director will apply evidence-based guidelines to decision making, collaborate with other senior leaders in efforts that enhance the quality of care delivery, improve outcomes, and improve value delivered to our key stakeholders.

Essential Position Functions/Responsibilities

• Support pre-admission review, utilization management, concurrent and retrospective review process and case management. Areas of responsibility may include Medical, Behavioral and Pharmaceutical services
• Provide professional leadership and direction in the utilization/cost management (UM) and clinical quality improvement (QI) of HCP, as measured by benchmarked UM and QI goals.
• Work collaboratively as a clinical resource to other plan functions that interface with medical management such as provider relations, provider services, claims management, Business Intelligence, etc.
• 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, as appropriate.
• 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 the 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 that satisfactory relationships are maintained 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.
• Perform other duties as assigned to support departmental and organizational goals.

Qualification Requirements

• 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.

Training/Education

• 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).

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.

Base Compensation

$260,000 - $285,000

Equal Employment Opportunity Statement

HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non-discrimination policy in every location where we operate. This policy applies to all aspects of employment, including but not limited to recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Job Disclaimer

The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs.