Director of Medical Reviews

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

• The Medical Director will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations.
• The Medical Director will render determinations in the format and within timeframes to follow Regulatory and Operational policies.
• The Medical Director will:
• Maintain productivity standards.
• Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages 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 the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed
• 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.

Minimum Qualifications

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

Preferred Qualifications

• 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
  
  
  
  

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
  
  

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.