Medical Director of Utilization Management

VillageCare; New York (NY); Hybrid; USD 180,000 - 260,000; Full time

Job summary

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.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Health plan UM

Clinical leadership

Appeals processes

Regulatory compliance

Inpatient/outpatient UM

Education

MD degree

NY medical license

MPH preferred

Job description

Position: Medical Director of Utilization Management

Location: 120 Broadway New York (Must Reside in NY/NJ/CT)

Work Schedule: Hybrid Full-Time

A little about us

VillageCare is a community-based, not-for-profit organization serving people with chronic care needs, as well as seniors and individuals in need of continuing care and managed care services. Our mission is to promote healing, better health and well-being to the fullest extent possible. Our care is offered through a comprehensive array of community and residential programs, as well as managed care. VillageCare has delivered quality health care services to individuals residing within New York City for over 45 years

Job Summary:

The Medical Director for VillageCareMAX is a physician who serves as clinical lead for the Utilization Management Department and medical quality and cost effectiveness activities. The Medical Director assists the VP of Medical Management to direct and coordinate medical management and quality improvement activities for the Health Plan.

Essential Job Functions:

• Responsible for providing oversight to the delivery of utilization management (UM) services and resources, consisting of case reviews for organizational determinations, peer to peer reviews and appeals
• Utilizes the care management system to document all case reviews
• Participates in case rounds/ICT meetings in the development of UM/CM plans for individual members to ensure appropriate continuity of care
• Analyzes utilization patterns, trends, and implements strategies to bring utilization patterns in line with expected benchmarks
• Responsible for successful compliance with regulatory and contractual requirements for Medical Management functions
• Participates in State and Federal Regulatory audits, investigations, surveys, and other reviews by the UM Department
• Maintains current knowledge of Federal and State regulatory requirements
• Develops and proposes annual goals and provides regular reports on progress toward accomplishing those goals

Experience:

• This position requires 3-5 years of health plan experience in medical management with Medicare and Medicaid Programs (specifically MLTC, MAP, DSNP and MAPD)
• Experience with both inpatient and outpatient utilization management (medical, pharmacy)
• Experience with appeal reviews
• NY Market Experience
• No New York Group or Hospital Affiliations

Education and certification:

• Medical Doctorate is required for this position.
• Master's Degree in public health is also preferred
• Certification: Required: Current and unrestricted Physician license to practice in NY
• Preferred: Board Certified, preferably internal medicine or emergency medicine or family medicine