Medical Director, Utilization & Quality Care

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

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