Medical Director, Utilization Management | Hybrid NY/NJ/CT

Village Care; New York (NY); Hybrid; USD 202,000 - 227,000; Full time

Job summary

VillageCare seeks a Medical Director of Utilization Management in New York City to lead the UM department and drive medical management and quality improvement for VillageCareMAX. This hybrid, full-time role partners with the VP to coordinate clinical and regulatory activities and ensure cost-effective, compliant care.

The position requires 3-5 years of health plan medical management experience (Medicare/Medicaid) and familiarity with inpatient/outpatient UM and appeals in the NY market.

Qualifications

• This position requires 3-5 years of health plan experience in medical management with Medicare and Medicaid Programs (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.

Responsibilities

• Oversight of utilization management services and resources, including case reviews for determinations, peer-to-peer reviews and appeals.
• Document all case reviews in the care management system.
• Participate in case rounds/ICT meetings to develop UM/CM plans for members.
• Analyze utilization patterns and implement strategies to align with benchmarks.
• Ensure compliance with regulatory and contractual requirements for Medical Management.
• Support audits, investigations, surveys and other reviews by UM.
• Maintain knowledge of Federal and State regulatory requirements.
• Develop and propose annual goals and report progress.

Job description

VillageCare seeks a Medical Director of Utilization Management in New York City to lead the UM department and drive medical management and quality improvement for VillageCareMAX. This hybrid, full-time role partners with the VP to coordinate clinical and regulatory activities and ensure cost-effective, compliant care.

The position requires 3-5 years of health plan medical management experience (Medicare/Medicaid) and familiarity with inpatient/outpatient UM and appeals in the NY market.