Remote Medical Director – Utilization

RCM Health Care Services; New York (NY); Remote; USD 260,000 - 275,000; Full time

Job summary

RCM Health Care Services seeks an experienced Medical Director for a health plan based in New York. This remote role focuses on utilization management, medical necessity reviews, and policy oversight to optimize patient care and reduce costs.

The position requires MD or DO, NY license, board certification/eligibility, and at least three years of clinical experience plus two years in managed care/utilization management.

Qualifications

• MD or DO degree from an accredited medical school.
• Valid New York State medical license and current registration to practice medicine.
• Board Certification or Board Eligibility.
• Minimum of three years of clinical experience.
• Minimum of two years of managed care experience in Utilization Management.

Responsibilities

• Perform Utilization Management, medical necessity, and appeal reviews across multiple lines of business, including Medicare.
• Conduct peer-to-peer discussions and provide physician education regarding clinical policies and medical management issues.
• Assist with new technology assessments and clinical policy reviews using evidence-based medical literature.
• Review claims and utilization patterns to identify opportunities to improve care, reduce unnecessary costs, and address potential fraud, waste, and abuse.
• Collaborate with case management and participate in Credentialing, Medical Policy, and other clinical committees as needed.

Skills

Clinical judgment

Utilization Management

Managed care

Communication skills

Collaboration

Education

MD/DO degree

Job description

Medical Director – Health Plan – Remote

Salary Range: $260,000 – $275,000 per year
Location: New York, NY
Remote / Onsite: Remote – Monday through Friday, Business Hours

Position Summary

RCM Healthcare Services is seeking an experienced Medical Director for a health plan in New York. This role is responsible for supporting appropriate healthcare utilization through Utilization Management, medical necessity and appeal reviews, peer-to-peer discussions, and clinical policy review. The Medical Director will work closely with physicians, case managers, and health plan medical leadership across multiple lines of business, including Medicare.

Responsibilities

• Perform Utilization Management, medical necessity, and appeal reviews across multiple lines of business, including Medicare.
• Conduct peer-to-peer discussions and provide physician education regarding clinical policies and medical management issues.
• Assist with new technology assessments and clinical policy reviews using evidence-based medical literature.
• Review claims and utilization patterns to identify opportunities to improve care, reduce unnecessary costs, and address potential fraud, waste, and abuse.
• Collaborate with case management and participate in Credentialing, Medical Policy, and other clinical committees as needed.

Requirements

Education

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited and approved medical school.

Licenses & Certifications

• Valid New York State medical license and current registration to practice medicine.
• Board Certified or Board Eligible.

Experience

• Minimum of three years of clinical experience.
• Minimum of two years of managed care experience, specifically within Utilization Management.

Skills

• Strong clinical judgment and medical decision-making skills.
• Knowledge of managed care and Utilization Management.
• Strong written and verbal communication skills.
• Ability to effectively collaborate with physicians, case managers, and other healthcare professionals.

About Us

RCM Healthcare Services works with professionals across schools, healthcare, and community-based settings nationwide. We support both contract and direct hire opportunities, connecting people early in their careers and experienced professionals to roles that align with their experience and preferences. With more than 50 years of staffing experience, our team understands the environments you’re stepping into and what it takes to be successful in them.

Equal Employment Opportunity & Reasonable Accommodation

RCM Technologies is an equal opportunity employer and values diversity. We are committed to providing reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act (ADA) and applicable state laws.