Utilization Management Representative Jobs in New York

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of"people caring for people," Martin's Point employees are on amission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary
 The Vice President, Medical Director, Health Plan provides senior clinical leadership across the Health Plan, with a focus on quality, affordability, compliance, clinical performance, and member outcomes. This role requires strong health plan experience, the ability to lead across functions, and the communication skills to influence clinical, operational, financial, regulatory, and executive stakeholders.
Job Description

Employees are expected to support and demonstrate the mission, vision, and core values of Martin's Point Health Care.

Key responsibilities include:

• Partner with Health Plan senior leadership to advance clinical outcomes, affordability goals, growth targets, and overall health plan strategy.

• Provide clinical leadership across utilization management, care management, population health, quality, pharmacy, medical policy, payment policy, and clinical program development.

• Lead cross-functional collaboration among Medical Directors, Medical Economics, Quality, Network, Compliance, Pharmacy, Operations, and Clinical Programs.

• Support compliance with government program requirements, including clinical appeals and grievances, using sound clinical evidence and medical judgment.

• Use clinical, quality, utilization, and financial data to identify trends, assess performance, and recommend actionable interventions.

• Develop strategies to improve medical expense management, appropriate utilization, quality of care, and population health outcomes.

• Provide clinical input into product design, Medicare bids, risk adjustment, STARS, HEDIS, value-based arrangements, and clinical integration initiatives.

• Communicate complex clinical, regulatory, and operational information clearly to executive, provider, clinical, and non-clinical audiences.

• Support appropriate utilization of services through strong partnership with Utilization Management, Care Management, and physician leaders.

• Represent the organization with regulatory entities, professional societies, providers, network partners, and external stakeholders, as appropriate.

• Build and strengthen relationships with hospitals, physicians, and other health care providers to support network engagement and performance goals.

• Support strategies tied to population health, care management, provider performance, and contractual outcomes.

• Lead, support, and develop physician leaders and clinical team members, as assigned.

Position QualificationsRequired

• Medical Degree, MD or DO, from an accredited medical school.

• Board certification in a relevant medical discipline or specialty.

• Active, unrestricted medical license, or ability to obtain licensure in a state relevant to the role.

• Ten or more years of professional experience, including clinical practice experience.

• Health plan, managed care, or payer experience in a Medical Director or comparable physician leadership role.

• Demonstrated experience working across health plan functions, such as utilization management, care management, quality, appeals and grievances, population health, medical economics, provider relations, pharmacy, compliance, or network.

• Experience using clinical, quality, utilization, or financial data to guide decisions, develop interventions, and measure outcomes.

• Strong cross-functional leadership skills, with the ability to align clinical, operational, financial, and regulatory priorities.

• Strong verbal, written, and presentation skills, including the ability to communicate effectively with executive, clinical, provider, operational, and regulatory audiences.

• Ability to influence, collaborate, and build credibility with internal and external stakeholders.

• Strong analytical, problem-solving, and decision-making skills.

• Demonstrated alignment with Martin's Point Health Care values.

Preferred

• Experience with Medicare Advantage, TRICARE, or other government-sponsored programs.

• Experience with STARS, RAF, risk adjustment, Medicare bids, HEDIS, or value-based care arrangements.

• Prior management or physician leadership experience.

• Experience supporting medical policy, payment policy, pharmacy, or clinical program development.

• Experience building relationships with network physicians, hospitals, and community providers.

Pay Range: $286,066.65 - $353,376.45 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan. In addition to base compensation, we offer a comprehensive benefits package including medical, dental, vision, retirement savings with employer contributions, paid time off (including volunteer time off!), pie day, and other employee benefits.
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org

Do you have a question about careers at Martin's Point Health Care? Contact us at:jobinquiries@martinspoint.org