[Hiring] Director of Medical Reviews @HealthFirst

Role Description

The Director, Medical Reviews position is responsible for conducting medical necessity reviews in the context of utilization management and appeals and managing the development and implementation of quality improvement initiatives.

Duties & Responsibilities:

• Assess/review requests for authorization and claims payment based on medical records and internal Healthfirst information.
• Render determinations in the format and within timeframes to follow Regulatory and Operational policies.
• Maintain productivity standards.
• Collaborate with Utilization Management and Care Management and medical departments as needed; review and manage cases/caseload from multiple lines of businesses.
• Design reports, analyze trends, and establish policies to ensure operation of a high quality, efficient program.
• Attend meetings in place of other Executive and Sr. Medical Directors.
• Demonstrate flexibility when case load volume fluxes and when Leadership requests changes in case priorities to support members/internal medical departments.
• Complete mandatory Company compliance training and training in new systems and software.
• Participate in Peer-to-Peer discussions with provider organizations upon request.
• Perform other duties as assigned.
• Provide weekend coverage as needed.
• Responsibilities may be adjusted based on changing needs of the organization.

Work Schedule:

• Each Medical Reviewer is required to work 8 hours a day, Monday through Friday. (This includes 1-2 weekends a month/4 hours a day)
• This position does not involve direct patient care.

Qualifications

• Licensed M.D. or D.O.
• Board Certified in a specialty recognized by the American Board of Medical Specialties.

Requirements

• Board Certified in Internal Medicine, Family Practice, OBGYN or Emergency Medicine.
• Previous relevant experience in utilization management and clinical practice.
• Knowledge of Medicare, Medicaid, and MLTC plans.
• Time management, critical thinking, communication, and critical thinking skills.
• Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies.
• Knowledge of member satisfaction/incident management and regulations.
• Knowledge of quality improvement methodologies.
• 5 years clinical experience.

Compliance & Regulatory Responsibilities

• Ensures compliance to internal Healthfirst and external regulations.
• NYS Licensed M.D, D.O. (Unrestricted NYS active license).
• Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades.
• Annual Inter-Rater Reliability (IRR) Testing.
• Complies with the Healthfirst Conflict of Interest Policy for Professionals.

Benefits

• Medical, dental, and vision coverage.
• Incentive and recognition programs.
• Life insurance.
• 401k contributions (all benefits are subject to eligibility requirements).

Hiring Range

• Greater New York City Area (NY, NJ, CT residents): $154,600 - $236,555.
• All Other Locations (within approved locations): $127,500 - $195,075.