Remote Medical Director — Utilization & Policy Innovation

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

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.