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