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Medical Director - Utilization Management
Burlington, Massachusetts, United States
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Job Summary

Occupation Physician
Specialty Pediatrics
Degree Required MD/DO
Position Type Permanent/Full-Time
Work Environment Hospital Clinic/Private Practice
Location Newark, New Jersey, United States
Visa Sponsorship No

Job Description

Last Update: 11/27/21

Medical Director (Internal Medicine, Med/Peds, Family Practice, Pediatrics or Emergency Medicine)

Position Purpose: Assist the VP of Clinical Programs to direct and coordinate the physician component of the utilization management functions for the health plan business units.

 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


Education/Experience: Requires a 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. The candidate must be an actively practicing physician. More than 1 state license is preferred.

License/Certifications: Board Certification through American Board Medical Specialties. Current state medical license without restrictions.


  • This position is for the UM Medical Director for the NJ Market. It is a new position for our market that will be responsible for utilization reviews, process development, policy development and updates, and appeals/grievances. This position will report to the chief medical officer of the market. • Over 90% transactional (mostly reviews)

  • Must have a medical license in New Jersey • Must live in the tri-state area and willing to travel within NJ

  • Flexible work hours (depending on business needs) • Flexible working location (home vs office) (depending on business needs) • “Start up” position: the market has never performed UM reviews/grievances/appeals at the market. This is an opportunity to set up processes from the start to improve the work experience and obtain positive results. • This is a leadership position that will work closely with the UM nursing staff and chief medical officer.