You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking a skilled Director of Utilization Management to oversee the delivery of utilization management services, including case reviews, peer reviews, and appeals. The successful candidate will ensure compliance with regulatory requirements, participate in audits and reviews, and contribute to the development and attainment of annual goals.
Key Responsibilities
- Responsible for oversight of utilization management services and resources through case reviews, peer reviews, and appeals.
- Document all case reviews utilizing the care management system.
- Participate in case rounds and ICT meetings to develop UM/CM plans for patient continuity of care.
- Analyze utilization patterns, trends, and implement strategies to align with expected benchmarks.
- Ensure compliance with regulatory and contractual requirements for Medical Management functions.
- Participate in State and Federal Regulatory audits, investigations, surveys, and reviews.
- Maintain current knowledge of Federal and State regulatory requirements.
- Develop and propose annual goals, providing regular progress reports.
Qualifications
- Medical Doctorate is required.
- Current and unrestricted Physician license to practice in New York.
- Preferred: Board Certification in internal medicine, emergency medicine, or family medicine.
- Preferred: Master’s Degree in public health.
Experience
- 3-5 years of health plan experience in medical management, particularly with Medicare and Medicaid Programs.
- Experience with both inpatient and outpatient utilization management, including medical and pharmacy utilization.
- Experience with appeal reviews.
- NY Market Experience.
Skills
- Strong ability to analyze utilization patterns and implement strategies for benchmark alignment.
- Effective communication skills for participation in audits, reviews, and cross-departmental collaboration.
Additional Requirements
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
*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).
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
Any required state or Joint Commission training is compensated at the state or local minimum wage rate.
*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.
