About the Opportunity
We are seeking an experienced Medical Director of Utilization Management in New York City to provide clinical leadership within our client’s growing health plan environment serving Medicare and Medicaid populations. This is an outstanding opportunity for a physician who enjoys collaborating across multidisciplinary teams, driving quality outcomes, ensuring regulatory compliance, and helping members receive the right care at the right time.
The annual base salary range is $200,000 to $225,000 Actual compensation offered to the successful candidate may vary from posted hiring range based upon geographic location, work experience, education, and/or skill level, among other things. Details about eligibility for bonus compensation (if applicable) will be finalized at the time of offer.
Job Responsibilities
- Serve as the physician leader and clinical resource for Utilization Management operations
- Conduct medical necessity reviews, peer-to-peer consultations, and appeal determinations
- Partner with executive leadership to develop and execute medical management initiatives
- Monitor utilization trends and identify opportunities to improve quality, efficiency, and cost-effectiveness
- Participate in interdisciplinary care planning discussions to support coordinated member care
- Ensure compliance with federal, state, accreditation, and contractual requirements
- Support organizational readiness for audits, surveys, regulatory reviews, and investigations
- Utilize care management platforms to document clinical reviews and decision-making activities
- Evaluate utilization data and performance metrics to support strategic planning efforts
- Contribute to annual departmental goals and provide ongoing progress updates
- Maintain current knowledge of evolving Medicare, Medicaid, and managed care regulations
- Collaborate with quality, care management, pharmacy, and operational teams to improve health outcomes
Job Requirements
- Medical Doctor (MD or DO) degree, licensed in NY
- Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, or related specialty
- 3+ years of experience in health plan medical management
- Experience supporting Medicare and Medicaid products, including managed care populations
- Background in utilization management across inpatient and outpatient settings
- Experience performing appeals reviews and medical necessity determinations
- Strong knowledge of New York healthcare market dynamics
What Makes You a Great Fit for This Role
- Strategic thinker with strong clinical judgment
- Excellent communicator who can build relationships across departments
- Data-driven leader focused on quality improvement and member outcomes
- Strong understanding of healthcare regulations and managed care operations
- Passion for improving access, affordability, and quality of care
