Medical Director (Remote) - Utilization Management

A New York City-based health services system is seeking a licensed professional to join their staff Remotely as their new Medical Director - Utilization Management.

About the Opportunity:

• Shift: Day
• Schedule: Monday to Friday
• Hours: Standard business
• Setting: Remote

Responsibilities:

• Perform utilization management across all lines of business, including Medicare.
• Conduct peer-to-peer discussions and educate physicians on policies and medical management issues.
• Support new technology assessment and clinical policy review through evidence-based research.
• Review medical necessity and appeal cases.
• Analyze utilization patterns, retrospective claims, and potential fraud, waste, and abuse indicators.

Qualifications:

• Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited and approved School of Medicine
• Minimum of 3 years of Clinical experience
• Minimum of 2 years of experience in a Managed Care setting, particularly Utilization Management
• Valid New York State medical license and current registration to practice medicine in New York
• Board certification or board eligibility

Desired Skills:

• Experience conducting case manager rounds.
• Experience participating in medical policy, credentials, or similar committees
• Exposure to out-of-network provider utilization management