Medical Director

Company: MetroPlus
Location: Newark
Posted on: January 11, 2021

Job Description:

About NYC Health + Hospitals MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus' network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. Position Overview The Associate Medical Director is responsible for assisting in ensuring appropriate health care utilization management (UM). The Associate Medical Director serves as a physician and policy advisor to the Plan's Chief Medical Officer. The Associate Medical Director (1) advise and work collaboratively with other plan functions that interact with medical management such as network relations, provider contracting, quality management, credentialing. Customer services, benefits and claims management , marketing , MIS and regulatory affairs; (2) assist in short and long -term strategic plans of the clinical revenue management program, quality improvement program ; and cost containment activities; and (3) assist and support the Chief Medical Officer to ensure cost effective health care services are provided to our members Job Description Conduct analyses to identify trends and patterns suggestive or indicative of:Inappropriate, unreasonable, or medically unnecessary care; inappropriate transfers; and Insufficient, poor documentation or patterns of failing to provide medical records.Performs Peer to Peer discussions, as applicable, and educates physicians and others on current policy, medical management issues.Assist the Chief Medical Officer in the identification and implementation of opportunities for improving the pre and post payment review process.Assist in new technology assessment and clinical policy review as required and has facility in researching the evidence -based literature, including use of comparable database.Perform other duties as needed and assigned by the Chief Medical Officer relevant to UM, Appeals and clinical policy process.Perform medical necessity reviews and appeal reviewsServe as co-chair for Credentialing CommitteeServe as co-chair of the Utilization Management SubcommitteeSupervise retrospective review of claims to identify practice patterns that could be improved to reduce costs and improve case (e.g., prompt outpatient follow-up of chest pain patients)Conduct analyses to identify trends and patterns suggestive of, or indicative of inappropriate or excessive use of services or equipmentPerform peer to peer discussions to explain MetroPlus policy and educate internal and external physicians Minimum Qualifications Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited and approved school of medicine.A minimum of three years clinical experienceA minimum of two years' experience in a managed care setting, in particular utilization management Licensure and/or Certification Required Valid and current license to practice medicine in the state of New York.Board Eligible/Certification Professional Competencies Integrity and TrustCustomer FocusFunctional/Technical SkillsWritten/Oral Communications

Keywords: MetroPlus, Newark , Medical Director, Executive , Newark, New Jersey