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Medical Director

Company: MetroPlus Health Plan
Location: Newark
Posted on: January 15, 2022

Job Description:

About NYC Health + HospitalsMetroPlus 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 Medical Director is responsible for assisting in ensuring appropriate health care utilization management (UM). The Medical Director serves as a physician and policy advisor to the Plan 's Chief Medical Officer. The 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, Call Center, Benefits and Claims Management , Sales, IT, 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 membersJob 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 reviews
  • Serve as co-chair for Credentialing Committee
  • Serve as co-chair of the Utilization Management Subcommittee
  • Supervise 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 equipment
  • Perform peer to peer discussions to explain MetroPlus policy and educate internal and external physiciansMinimum Qualifications
    • Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited and approved school of medicine.
    • A minimum of three years clinical experience
    • A minimum of two years ' experience in a managed care setting, in particular utilization managementLicensure and/or Certification Required
      • Valid and current license to practice medicine in the state of New York.
      • Board Eligible/CertificationProfessional Competencies
        Integrity and Trust
        Customer Focus
        Functional/Technical Skills
        Written/Oral Communications

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

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