Medical Director of Utilization Management (MD/DO) (255057)

Medix™ · New york, United States

Title: Medical Director of Utilization Management

Summary: Step into a strategic leadership position as the Clinical Lead for a prominent Health Plan's Utilization Management (UM) Department. You will oversee clinical strategy, quality improvement, and cost-effectiveness across government-sponsored health programs in New York.

Day to Day:

• Provide clinical oversight for UM services, complex case reviews, appeals, and peer-to-peer discussions.
• Document case reviews and rationales in enterprise care management software.
• Join Interdisciplinary Care Team (ICT) rounds to support care continuity for members.
• Analyze regional utilization trends and implement strategies to meet benchmarks.
• Ensure regulatory compliance and lead departmental preparation for State/Federal audits.
• Propose annual goals and deliver progress reports to executive leadership.

Shift:

• Monday – Friday, 9:00 AM – 5:00 PM
• Hybrid schedule (2 days/week in-office in NYC; must reside in NY, NJ, or CT).

Qualifications:

• Education & Licensure: MD or DO with an active, unrestricted NY medical license.
• Experience: 4 - 5 years in health plan medical management with Medicare/Medicaid (MLTC, MAP, D-SNP, MAPD).
• Scope: Experience with inpatient/outpatient UM, medical necessity, pharmacy, and appeals.
• Certifications: Board Certification preferred (Internal, Family, or Emergency Medicine). MPH/MHA a plus.
• Requirement: Must have no active group practice or hospital affiliations in New York.

Perks!:

• Competitive Salary: $275,000 - 315,000 / year
• High-impact leadership role with a hybrid schedule (3 days remote / 2 days onsite)