Vice President of Medical Directors

Company: MetroPlus Health Plan
Location: New York
Posted on: April 19, 2024

Job Description:

Vice President of Medical Directors



Job Ref: 100616

Category: Utilization Review and Case Management

Department: UTILIZATION MANAGEMENT

Location: 50 Water Street, 7th Floor,

New York,
NY 10004


Job Type: Regular

Employment Type: Full-Time



Salary Range: $340,000.00 - $350,000.00








Empower. Unite. Care.MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.About NYC Health + HospitalsMetroPlusHealth 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, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth 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 Vice President of Medical Directors serves in a policy, operational and strategic capacity. The Vice President of Medical Directors' 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.Job Description

• 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 OfficerMinimum Qualifications
  • 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 CertificationProfessional Competencies:
      • Integrity and Trust
      • Customer Focus
      • Functional/Technical skills
      • Written/Oral Communication#LI-Hybrid
        
        
        
        
        

Keywords: MetroPlus Health Plan, Hempstead , Vice President of Medical Directors, Executive , New York, New York