Hybrid Medical Director — Utilization & Quality Management

VillageCare; New York (NY); Hybrid; USD 180.000 - 260.000; Vollzeit

Zusammenfassung

VillageCare is seeking a Medical Director of Utilization Management in New York. The role leads the UM department, ensuring medical quality and cost-effectiveness for VillageCareMAX, and supports the VP of Medical Management in coordinating medical management and quality improvement for the Health Plan.

You will oversee UM services, document case reviews, participate in rounds, and drive utilization strategies while maintaining compliance with state and federal regulations.

Qualifikationen

• This role requires 3–5 years in health plan utilization management.
• Experience with Medicare/Medicaid programs and MLTC/MAP is preferred.
• Current NY license to practice medicine is required.

Aufgaben

• Oversee utilization management services, including case reviews and appeals.
• Document case reviews in the care management system.
• Participate in case rounds to develop UM plans for members.
• Analyze utilization patterns and align with benchmarks.
• Ensure regulatory and contractual compliance for Medical Management.
• Assist in audits, investigations, and surveys for UM.
• Maintain up-to-date knowledge of federal and state requirements.

Kenntnisse

Health plan UM

Clinical leadership

Appeals processes

Regulatory compliance

Inpatient/outpatient UM

Ausbildung

MD degree

NY medical license

MPH preferred

Jobbeschreibung

VillageCare is seeking a Medical Director of Utilization Management in New York. The role leads the UM department, ensuring medical quality and cost-effectiveness for VillageCareMAX, and supports the VP of Medical Management in coordinating medical management and quality improvement for the Health Plan.

You will oversee UM services, document case reviews, participate in rounds, and drive utilization strategies while maintaining compliance with state and federal regulations.