Medical Director - UM Reviewer; Part-Time

Health Care Partners, IPA and Health Care Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, Health Care 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. Interested in joining our successful Garden City Team?

We are currently seeking a Medical Director – UM Reviewer
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The Medical Director will be responsible for assuring appropriate and optimized health care delivery for members. This position is primarily responsible for conducting medical necessity reviews, including prior authorizations, concurrent reviews, retrospective reviews, and appeals determinations. This role will focus on efforts to achieve excellence in healthcare cost management, quality, member experience, and improved population and member outcomes. They will serve as a clinical expert for teams dedicated to concurrent review, prior authorization, case management and strategic program development and implementation.

The Medical Director will serve as a resource for our IPA physicians. The Medical Director will apply evidence-based guidelines to decision making, collaborate with other senior leaders in efforts that enhance the quality of care delivery, improve outcomes, and improve value delivered to our key stakeholders.

• Support pre-admission review, utilization management, concurrent and retrospective review process and case management. Areas of responsibility may include Medical, Behavioral and Pharmaceutical services
• Provide professional leadership and direction in the utilization/cost management (UM) and clinical quality improvement (QI) of HCP, as measured by benchmarked UM and QI goals.
• Work collaboratively as a clinical resource to other plan functions that interface with medical management such as provider relations, provider services, claims management, Business Intelligence, etc.
• Ensure members receive safe, effective, equitable, efficient, timely and patient-centered health care services within their health plan benefits.
• Carry out medical policies consistent with NCQA and other regulatory bodies.
• Participate and/or chair clinical committees and work groups as assigned.
• Review medical care, medical service, and pharmacy requests against established clinical guidelines and make approval and denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
• Identify potentially unnecessary services and care delivery settings, and recommend alternatives, as appropriate.
• Review appeals of medical and pharmacy denials against established clinical guidelines and make approval and denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
• Participate in an after-hours telephonic on-call rotation to provide clinical guidance and support for urgent matters…