HealthCare Partners
Medical Director - UM Reviewer
HealthCare Partners, East Garden Mobile Home Village, Kansas, United States
Medical Director – UM Reviewer (Garden City, NY)
HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician‑owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 200+ skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources.
HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care. Join our successful Garden City Team as a
Medical Director – UM Reviewer .
Position Summary The Medical Director will assure appropriate and optimized health care delivery for members. Primary responsibilities include conducting medical necessity reviews—prior authorizations, concurrent reviews, retrospective reviews, and appeals determinations—to achieve excellence in healthcare cost management, quality, member experience, and improved population and member outcomes. The role serves as a clinical expert for teams dedicated to concurrent review, prior authorization, case management, and strategic program development and implementation. The Medical Director applies evidence‑based guidelines to decision making, collaborates with senior leaders, and enhances the quality of care delivery and value to stakeholders.
Essential Position Functions / Responsibilities
Support pre‑admission review, utilization management, concurrent and retrospective review process, and case management across medical, behavioral, and pharmaceutical services.
Provide professional leadership in utilization/cost management and clinical quality improvement, meeting benchmarked UM and QI goals.
Collaborate as a clinical resource with provider relations, provider services, claims management, business intelligence, and other plan functions.
Ensure safe, effective, equitable, efficient, timely, and patient‑centered health care services within plan benefits.
Carry out medical policies consistent with NCQA and other regulatory bodies.
Participate in or chair clinical committees and work groups as assigned.
Review medical and pharmacy requests against established clinical guidelines, making approval and denial determinations in accordance with evidence‑based standards and regulatory requirements.
Identify and recommend alternatives for unnecessary services and care delivery settings.
Review appeals of medical and pharmacy denials.
Participate in an after‑hours telephonic on‑call rotation to provide clinical guidance for urgent matters.
Identify opportunities for corrective action plans to improve organizational performance.
Collaborate with provider networks, quality, and medical management to create incentive programs targeting utilization, cost, and quality outcomes.
Analyze performance data from paid claims and other sources.
Provide periodic written and verbal reports on utilization, case management, and quality management.
Support NCQA qualification activities, site visits, and regulatory compliance.
Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, credentialing, provider orientation, and profiling.
Conduct quality improvement and outcome studies as directed by state and federal regulatory agencies.
Support the grievance process and ensure fair outcomes.
Monitor member and provider satisfaction survey results, implementing changes to increase satisfaction.
Chair various HCP committees such as UM, CM, peer review, and credentialing.
Promote wellness and preventive outreach to members and providers.
Conduct in‑service staff training and education.
Contribute to strategic planning and program development.
Participate in key marketing activities as needed.
Perform other duties as assigned.
Qualification Requirements Skills, Knowledge, Abilities
In‑depth knowledge of utilization management practices in a managed care setting.
Familiarity with NCQA, CMS, state Medicaid, and other regulatory guidelines.
Strong analytical, organizational, and clinical decision‑making skills.
Excellent written and verbal communication skills.
Proficiency with utilization management tools and platforms (e.g., InterQual, MCG, care management systems).
Demonstrated ability to work effectively across teams.
Understanding of value‑based care models and population health strategies.
Training / Education
MD or DO degree required.
Board certification required (ABMS or AOA recognized specialty).
Active, unrestricted license to practice medicine in the state(s) of operation (e.g., New York).
No history of sanctions from state licensing boards or federal healthcare programs (e.g., Medicare, Medicaid).
Experience
Minimum of 5 years of clinical practice experience.
Minimum of 2 years of experience in a managed care environment or utilization management role strongly preferred.
Experience with medical necessity review, clinical guideline interpretation, and appeal and grievance processes highly desirable.
Base Compensation $260,000 – $285,000
Equal Employment Opportunity Statement HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non‑discrimination policy in every location where we operate. This policy applies to all aspects of employment, including recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leave of absence, compensation, and training.
Job Disclaimer The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs.
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HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care. Join our successful Garden City Team as a
Medical Director – UM Reviewer .
Position Summary The Medical Director will assure appropriate and optimized health care delivery for members. Primary responsibilities include conducting medical necessity reviews—prior authorizations, concurrent reviews, retrospective reviews, and appeals determinations—to achieve excellence in healthcare cost management, quality, member experience, and improved population and member outcomes. The role serves as a clinical expert for teams dedicated to concurrent review, prior authorization, case management, and strategic program development and implementation. The Medical Director applies evidence‑based guidelines to decision making, collaborates with senior leaders, and enhances the quality of care delivery and value to stakeholders.
Essential Position Functions / Responsibilities
Support pre‑admission review, utilization management, concurrent and retrospective review process, and case management across medical, behavioral, and pharmaceutical services.
Provide professional leadership in utilization/cost management and clinical quality improvement, meeting benchmarked UM and QI goals.
Collaborate as a clinical resource with provider relations, provider services, claims management, business intelligence, and other plan functions.
Ensure safe, effective, equitable, efficient, timely, and patient‑centered health care services within plan benefits.
Carry out medical policies consistent with NCQA and other regulatory bodies.
Participate in or chair clinical committees and work groups as assigned.
Review medical and pharmacy requests against established clinical guidelines, making approval and denial determinations in accordance with evidence‑based standards and regulatory requirements.
Identify and recommend alternatives for unnecessary services and care delivery settings.
Review appeals of medical and pharmacy denials.
Participate in an after‑hours telephonic on‑call rotation to provide clinical guidance for urgent matters.
Identify opportunities for corrective action plans to improve organizational performance.
Collaborate with provider networks, quality, and medical management to create incentive programs targeting utilization, cost, and quality outcomes.
Analyze performance data from paid claims and other sources.
Provide periodic written and verbal reports on utilization, case management, and quality management.
Support NCQA qualification activities, site visits, and regulatory compliance.
Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, credentialing, provider orientation, and profiling.
Conduct quality improvement and outcome studies as directed by state and federal regulatory agencies.
Support the grievance process and ensure fair outcomes.
Monitor member and provider satisfaction survey results, implementing changes to increase satisfaction.
Chair various HCP committees such as UM, CM, peer review, and credentialing.
Promote wellness and preventive outreach to members and providers.
Conduct in‑service staff training and education.
Contribute to strategic planning and program development.
Participate in key marketing activities as needed.
Perform other duties as assigned.
Qualification Requirements Skills, Knowledge, Abilities
In‑depth knowledge of utilization management practices in a managed care setting.
Familiarity with NCQA, CMS, state Medicaid, and other regulatory guidelines.
Strong analytical, organizational, and clinical decision‑making skills.
Excellent written and verbal communication skills.
Proficiency with utilization management tools and platforms (e.g., InterQual, MCG, care management systems).
Demonstrated ability to work effectively across teams.
Understanding of value‑based care models and population health strategies.
Training / Education
MD or DO degree required.
Board certification required (ABMS or AOA recognized specialty).
Active, unrestricted license to practice medicine in the state(s) of operation (e.g., New York).
No history of sanctions from state licensing boards or federal healthcare programs (e.g., Medicare, Medicaid).
Experience
Minimum of 5 years of clinical practice experience.
Minimum of 2 years of experience in a managed care environment or utilization management role strongly preferred.
Experience with medical necessity review, clinical guideline interpretation, and appeal and grievance processes highly desirable.
Base Compensation $260,000 – $285,000
Equal Employment Opportunity Statement HealthCare Partners, MSO is committed to fostering a diverse and inclusive workplace. We provide equal employment opportunities (EEO) to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other protected status under federal, state, or local laws. In compliance with all applicable laws, HealthCare Partners, MSO upholds a strict non‑discrimination policy in every location where we operate. This policy applies to all aspects of employment, including recruitment, hiring, placement, promotion, termination, layoff, recall, transfer, leave of absence, compensation, and training.
Job Disclaimer The above job description outlines the general scope and responsibilities of the position. It is not intended to be an exhaustive list of duties, skills, or qualifications required. Responsibilities may evolve based on business needs.
#J-18808-Ljbffr