Permanent Internal Medicine: Outpatient Only Job in Newark, New Jersey

• Position Type: Permanent
• Recruited Specialty: Internal Medicine: Outpatient Only
• Does the Physician Need To Be Trained In Specialty Being Recruited: Yes
• Structure of Position: Admin/Medical Director
• Partnership Opportunity: Unknown
• Expected Patient Call Coverage: No call
• Expected ER Call Coverage: No call

Job Summary: New position for the NJ Market. “Start-up” position: the market has never performed reviews/grievances/appeals in this market. This is an opportunity to set up processes from the start to improve the work experience and obtain positive results.

• Position is responsible for utilization reviews, process development, policy development and updates, and appeals/grievances. Over 90% transactional (mostly reviews).

• Assists the VP of Clinical Programs to direct and coordinate the physician component of the utilization management functions for the health plan business units.

• Reports to the Chief medical officer of the market.

• Flexible work hours (depending on business needs)

• Flexible working location (home vs office) (depending on business needs)

• Must live in the Tri-state area and willing to travel within NJ

Competitive base, relocation assistance, 20% bonus eligible

Medical Director Job Qualifications:
• Medical Doctor or Doctor of Osteopathy
• Board certified preferably in a primary care specialty (Internal Medicine, Med/Peds, Family Practice, Pediatrics or Emergency Medicine) or other specialty familiar with Medicare patients
• Previous experience within a managed care organization is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred
• Experience treating or managing care for a culturally diverse population preferred.
• Must be an actively practicing physician
• More than one state license is preferred
• NJ State medical license without restrictions
• Seeking someone who is flexible, a quick learner and able to work in a fast paced environment

What you will be doing:
• Provides medical leadership for utilization management activities and medical review activities pertaining to utilization review, quality assurance, medical review of complex, and controversial or experimental medical services such as transplants utilizing the services of consultants
• Performs case reviews and appeals for all health plans.
• Assists VP of Clinical Programs in planning, establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment

For consideration, please send cv to (Registered Profile Required)

• Location of Medical Training: American Medical Graduate (AMG), Foreign Medical Graduate (FMG)
• Medical Training Type: Allopathic (MD), Osteopathic (DO)
• Board Certification: Board Certified
• Work Status Requirements: US Citizen, Green Card
• Preferred Experience Level: Recently Trained, Experienced, Very Experienced
• Accept Local Physicians within 25 mile Radius: Yes

• Facility Type: Clinic
• Number of Providers: