Medical Doctor Utilization Management Specialist

5 days ago


Yonkers, New York, United States Smith Arnold Partners Full time
Medical Doctor Utilization Management Physician Advisor

We are seeking a highly skilled Medical Doctor to join our Utilization Management Department as a Physician Advisor. As a key member of our team, you will work collaboratively with utilization management, quality, and clinical teams to ensure that patients receive medically necessary, clinically appropriate, and high-quality care.

Key Responsibilities:
  • Perform medical necessity reviews and determine clinical appropriateness of care
  • Examine resource utilization and conduct reconsiderations with payors' medical directors
  • Communicate with clinical teams to ensure accurate documentation and severity of illness
  • Act as a resource to clinical, care management, and non-clinical staff, identifying opportunities for process improvement
  • Conduct resource utilization reviews to improve healthcare efficiency and costs
Requirements:
  • Must hold a New York Medical Doctor License and current registration
  • A minimum of 5 years' inpatient acute care clinical experience
  • Working knowledge of CMS's two-midnight rule, Medicare coverage criteria, and associated regulatory and payer requirements
  • Experience in population health, clinical integration, and cost containment activities, along with managed care experience and utilization management

Why this role matters: As a Physician Advisor, you will play a critical role in ensuring that our patients receive the highest quality care while also helping to improve healthcare efficiency and costs. If you are a motivated and detail-oriented Medical Doctor with a passion for utilization management, we encourage you to apply for this exciting opportunity.



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