Medical Director

VNS Health; New York (NY); On-site; USD 173,000 - 231,000; Full time

Benefits offered by this job

Referral bonuses

30 days PTO + 9 holidays

Health insurance

Employer-matched retirement

FSAs

Tuition reimbursement

Career advancement

CEU credits

Job summary

VNS Health seeks an experienced physician to guide utilization management for our members. You will review clinical information against evidence-based guidelines, render coverage decisions, and support internal and external teams with timely, compliant determinations.

Requires Medical Degree and state license, 5+ years in clinical medicine with managed care; strong communication and decision-making skills. Board certification in Internal or Family Medicine is preferred; geriatric care experience

Qualifications

• Medical Degree required.
• Licensed to practice medicine in state of residence.
• Five years of experience in clinical medicine, including three years in managed care.
• Experience applying evidence-based medical necessity criteria and CMS guidance.
• Geriatric medicine experience preferred.
• Board certification in Internal or Family Medicine preferred.
• Strong communication and influential skills required.

Responsibilities

• Provides medical determinations for Utilization Management and appeals.
• Reviews internal staff or external provider rationales related to coverage decisions.
• Reviews relevant medical records and clinical information for reviews.
• Uses evidence-based guidelines (Medicare NCDs, LCDs, Medicaid, MCG).
• Provides clinical case summaries and determination rationale; member letter verbiage.
• Ensures decisions deadlines are met and compliant with policies.
• Completes peer-to-peer consultations as required.
• Participates in interdisciplinary rounds.
• Reviews Quality of Care concerns and case summaries; assists with case-level assignments.
• Participates in special projects and other duties as assigned.

Skills

Strong communication

Influential skills

Critical thinking

Education

Medical Degree

Job description

Overview

Oversees the utilization of medical care and treatment of VNS MSO members and provides direction and guidance to the staff to assure appropriate and expedient decision-making with attention to quality of care. Consults and cooperates with internal and external partners. Works under general direction.

What We Provide:

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities.

What You Will Do:

• Provides medical determinations for purposes of Utilization Management (UM), initial and internal appeals decisions. This includes review of clinical information provided against evidence-based guidelines, ensure plan compliance with regulatory requirements, focus on improving quality of care, and support departments of VNS MSO that request medical review services.
• Reviews internal staff or external provider rationales related to coverage decisions.
• Reviews relevant medical records and clinical information on file in the context of performing clinical reviews. (e.g.: inpatient hospital records, outpatient professional notes, Letters of Medical Necessity (LOMN), assessment reports, etc.)
• Utilizes appropriate, evidence-based guidelines for reviews and organizational determination such as. (e.g.: Medicare NCDs, LCDs, Medicaid guidelines, MCG guidelines, VNS Health policies, etc.)
• Provides clinical case summary and determination rationale and member letter verbiage as appropriate.
• Ensures decisions deadlines are met and adhere by business goals and ensure compliance.
• Completes and documents peer-to-peer consultation according to policy through completion of any finalized decision.
• Participates in interdisciplinary rounds.
• Reviews Quality of Care (QOC) concerns, care records and QOC summary. Assist with case summary, case level assignment and recommended next steps.
• Participates in special projects and performs other duties as assigned.

Qualifications

Licenses and Certifications: Licensed to practice medicine in state of residence required. Licensed to practice medicine in New York State preferred. Specialty Board Certified or Eligible required. Board Certification in Internal or Family Medicine preferred. Certification in Geriatric Care preferred.

Education: Medical Degree required

Work Experience: Minimum five years of experience in clinical medicine, including three years in managed care, and application of evidence based medical necessity criteria and CMS guidance required. Prior experience in geriatric medicine preferred Prior experience in Utilization Management (UM) and/or a Medical Services Organization preferred. Demonstrated strong knowledge of Medicare and Medicaid regulatory and reporting requirements required. Strong communication and influential skills required. Exceptional critical thinking and decision-making skills preferred

Pay Range

USD $172,900.00 - USD $230,500.00 /Yr.

About Us

VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We're one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day.