Utilization Reviewer Jobs in Rochester, NY (NOW HIRING)

Job Description:

Summary:

The Senior Medical Director is a strategic clinical and business leader responsible for advancing the health plan's line of business focus through value-based care, population health, medical management, quality improvement, risk adjustment, product design, and clinical transformation. This role partners closely with line of business leadership, network and provider contracting, actuarial, finance, quality, pharmacy, analytics, care management, and operations to improve clinical outcomes, member experience, provider performance, and total cost of care while ensuring compliance with CMS requirements.

Essential Accountabilities:

• Serve a senior clinical advisor to line of business leadership on strategy, population health, medical cost, quality, and regulatory priorities, develop and execute clinical strategy in alignment with organizational growth, quality, and financial objectives.
• Identify clinical and market opportunities to improve member outcomes and competitive performance by translating clinical, utilization, quality, and financial data into actionable strategies and operating priorities.
• Establish provider performance expectations, clinical benchmarks, scorecards, and improvement strategies.
• Provide clinical leadership for medical management programs, including utilization management, prior authorization, concurrent review, case management, and care coordination by developing strategies to optimize site of care and reduce avoidable inpatient admissions, readmissions, emergency department utilization, and unnecessary high-cost services.
• Identify opportunities to improve preventive care, chronic disease management, medication adherence, member experience, and other quality measures by partnering with operational leaders to ensure medical management programs are clinically sound, member-centered, consistent, and compliant.
• Partner with Quality leadership to develop and execute quality improvement strategies monitoring performance against key quality metrics, including medical expense, PMPM trends, utilization, risk-adjusted performance, quality, and VBP results.
• Apply current knowledge of CMS, NYS and NCQA requirements, applicable federal regulations, and evolving payment and quality methodologies to support aligned business area(s).
• Performs appeals and case reviews on claims and pre-authorization requests.
• For Medicare line of business (LOB) only: Partner with Compliance, Legal, and Regulatory Affairs on Medicare-related initiatives and audits.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Minimum Qualifications:

• Degree in medicine, either an M.D. or D.O, board certification and an unrestricted active NYS Medical license required.
• Three (3) years of experience as a Medical Director for a health plan or equivalent experience required.
• Demonstrated ability to influence physicians, providers, executives, and cross-functional teams.
• Experience in designing and supporting shared savings, shared risk, capitation, global risk, bundled payment, and other value-based arrangements in MA.
• Strong analytical and financial acumen, with the ability to connect clinical interventions to medical expense, risk-adjusted revenue, and overall business performance.
• Strong verbal, written and interpersonal communication skills.
• Demonstrable understanding of managed care and delivery structures of healthcare.
• Working knowledge of CMS, NYS and NCQA requirements, applicable federal regulations, and evolving payment and quality methodologies.

For Medicare LOB only:

• At least 5 years of progressive leadership experience in Medicare Advantage, managed care, population health, health plan, ACO, provider organization, or a comparable environment required.
• Extensive Medicare Advantage experience, including the ability to develop and execute clinical strategies that drive measurable improvements in quality performance, utilization management, risk-adjusted outcomes, and value-based payment initiatives.
• Demonstrated expertise in Medicare Advantage and the healthcare economics of risk-based populations. Developing and optimizing provider incentive structures incorporating quality, utilization, total cost of care, risk adjustment, and member outcomes.
• Strong understanding of Medicare risk adjustment, CMS-HCC methodology, clinical documentation, and RADV requirements.

Physical Requirements:

• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
• Must have a valid Class D license and ability to operate a motor vehicle.

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In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

$249,840 -$374,760

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.