Director of Medical Reviews

Job description

The Director, Medical Reviews position is responsible for conducting medical necessity reviews in the context of utilization management and appeals and managing the development and implementation of quality improvement initiatives. Duties & Responsibilities: - The Medical Director will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations. - The Medical Director will render determinations in the format and within timeframes to follow Regulatory and Operational policies. The Medical Director will: - Maintain productivity standards. - Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses - Design reports, analyze trends and establish policies to ensure operation of a high quality, efficient program - Attend meetings in place of other Executive and Sr. Medical Directors - Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as need...