Medical Director – Utilization Management
Location: Hybrid – New York, NY 10005 (Must reside in NY, NJ, or CT)
Schedule: Monday–Friday | 9:00 AM – 5:00 PM
Work Model: Hybrid (2 days onsite per week)
Compensation: $210,000– $227,033 annually
Position Overview
We are seeking an experienced Medical Director of Utilization Management to provide clinical leadership for a growing managed care organization. This physician leader will oversee utilization management operations, medical necessity determinations, quality improvement initiatives, regulatory compliance, and interdisciplinary collaboration to ensure high-quality, cost-effective care for members.
Key Responsibilities
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Provide clinical oversight for utilization management, including medical necessity determinations, complex case reviews, peer-to-peer consultations, and appeals.
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Document clinical reviews and determinations within the organization's care management platform.
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Collaborate with interdisciplinary care teams to develop comprehensive utilization and care management plans.
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Analyze utilization trends and implement strategies to improve quality, efficiency, and resource utilization.
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Ensure compliance with all state, federal, and contractual medical management requirements.
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Lead preparation for regulatory audits, investigations, surveys, and external reviews.
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Stay current on evolving healthcare regulations affecting Medicare and Medicaid programs.
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Develop annual departmental goals and provide leadership with regular performance updates.
Qualifications
Required
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MD or DO with an unrestricted New York medical license.
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3–5 years of Medical Management experience within a health plan.
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Extensive experience with Medicare and Medicaid programs, including:
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Experience with both inpatient and outpatient utilization management.
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Strong background in medical necessity reviews, appeals, and peer-to-peer consultations.
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Knowledge of pharmacy utilization management and formulary considerations.
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Familiarity with the New York managed care market and regulatory environment.
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No active New York hospital or group practice affiliations.
Preferred
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Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine.
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Master's degree in Public Health (MPH), Healthcare Administration (MHA), or related field.
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Experience participating in state and federal regulatory audits.
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Proficiency with enterprise care management and electronic health record (EHR) systems.
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Experience developing population health, preventive care, or disease management initiatives.
Why Consider This Opportunity?
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Executive-level physician leadership role within managed care.
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Opportunity to shape utilization management strategy and quality initiatives.
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Hybrid work schedule with only two days onsite each week.
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Collaborative leadership environment focused on improving healthcare outcomes.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
