MetroPlus Health 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 Health 's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus Health has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

Responsible and accountable to the Chief Medical Officer for helping to manage health plan medical quality, utilization, and assuring appropriate health care delivery, the Senior Medical Director serves in a policy, operational and strategic capacity. The Senior Medical Director overall purpose is to work across medical management functions, with a focus on Utilization Management and Business Intelligence, and across all lines of business and pharmacy. This is a broad function that includes day-to-day operations, data and reporting design, high-level strategy, planning, and policy involvement.

• Reviews cases, determines medical necessity, and consults with physicians to review length of stay and reimbursement documentation.
• Supports Utilization Management (UM) department staff and nurse Care Managers on concurrent review and preauthorization referrals and ensures that members receive appropriate services consistent with their benefits, regulatory requirements, and established clinical criteria.
• Works with the VP of Clinical Services, who oversees day-to-day UM operations.
• Provides clinical support for member and provider appeals.
• Builds a health informatics function and ensures decisions are made according to data insights.
• Assists in new technology assessment and clinical policy review as required.
• Responsible for implementation of ongoing changes in policy and procedures from state and government entities.
• Participates in the development of strategic planning for existing and expanding business.
• Represents the health plan at regulatory meetings held by the New York State Department of Health, the New York City Department of Health and Mental Hygiene, and managed care trade organizational meetings as necessary.
• The VP of Medical Directors will be required to come to MetroPlusHealth HQ once a week (preferably on Thursdays)
• Performs other duties as needed and assigned by the Chief Medical Officer

• Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited and approved school of medicine.
• A minimum of three years' clinical experience post-residency
• A minimum of five years' experience in a managed care setting with at least 3 years specifically overseeing Utilization Management.
• Proven experience with heath informatics/data sciences and regulatory compliance
• Experience with NYS regulations and compliance is strongly preferred.

Licensure and/or Certification Required

• Valid and current license to practice medicine in the state of New York.
• Board Certification

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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