Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Medical Director

📁
Director and Equivalent
📅
200CE Requisition #
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Manage the daily clinical operation and administration of a Medical Management Department or function to support improved utilization results across the spectrum of medical specialties.  Provide clinical leadership both internally and externally.  Serve as an essential liaison among Senior Management, Plan staff, contracted providers, vendors, and membership to promote and improve communication and operations areas of medicine including Internal Medicine, OB/GYN, Psychiatry, Ambulatory Medicine, Emergency Medicine and Radiology.  Carry out assigned programs to assure the delivery of quality medical care to the EmblemHealth membership, ensuring compliance with contractual obligations and standards, and assisting in the development and implementation of new policy and programs as needed.  Ensure operational effectiveness and oversight of assigned functions, assuring regulatory compliance and accreditation with Department of Health, Department of Insurance, CMS, NCQA, and URAC standards.

Responsibilities:
  • Manage use of medical resources for inpatient and outpatient services including Internal Medicine, OBGYN, Neurology, Surgery, Pediatrics, Emergency Medicine or Psychiatry. 
  • Determine medical appropriateness through the application of clinical criteria; perform case management review; and, participate in the clinical appeals process. 
  • Sole authority and responsibility for issuing clinical adverse determinations based on medical necessity. 
  • Conduct medical rounds, attend Medical Director meetings and participate in the inter-rater reliability process. 
  • May also perform peer clinical reviews as needed. (See Addendum for expanded description of this activity).
  • Establish and maintain continuity in the planning, development and implementation of policies, operational processes, workflows required to execute organizational strategies and to assure consistency in process application throughout Care Management.  
  • Validate and monitor adherence to implemented policies, procedures, workflows and processes:  identify, recommend and implement improvement initiatives accordingly.  
  • Generate methods to develop and improve the overall delivery and performance of the department.  
  • Implement process improvements in a timely manner.  
  • Deal effectively with and lead others throughout Company structure.  
  • Support other areas in implementing cross-departmental changes.  
  • Make sound decisions based on all available data. 
  • Determine medical appropriateness through the application of clinical criteria and performs case management review.
  • Develop annual goals and oversight of assigned department/function.
  • Demonstrated familiarity with high risk populations, community settings and care of medical patients.
  • Provide thought leadership to articulate and help build an effective and efficient medical delivery program.
  • Support Senior Medical Directors in communications with internal and external organizational goals; ensure a high level of customer satisfaction (members, vendors, providers, regulators, accreditation agencies, peers and employees).
  • Anticipate and identify key source information to analyze problems clearly and determines creative solutions.
  • Identify trends, problems and opportunities, conduct root cause analysis.  
  • Implement action plans in an effective and efficient manner aimed at promoting goals/resolving barrier issues.
  • Strive to improve efficiencies of key operational areas.  
  • Assist with contract negations as necessary.  
  • Represent Care Management in interdepartmental committees designed to meet organizational goals.
  • Chair or participate on committees as requested.
  • Regular attendance is an essential function of the job.  Performs other duties as assigned or required.
Qualifications:
  • MD or DO degree. Board certification is required
  • Active New York license or certification to practice medicine without restriction required
  • 5 years of clinical practice required
  • Administrative experience on a hospital committee, in a medical group or for an insurer preferred
  • Knowledge of clinical practice of medicine, health care delivery systems, utilization methods and treatment
  • Protocols required
  • Knowledge and understanding of managed care principles, industry evolution, physician reimbursement, and human resource management required
  • Experience conducting evidence-based treatments in group and individual modalities, especially for psychiatric treatment preferred
  • Considerable independent decision making with physicians, members, subordinates, other departmental leaders and external vendors, regulatory and accreditation agencies required
  • Communication skills both oral and written, tact and diplomacy sufficient to successfully carry out the above duties and responsibilities required
  • Knowledge of clinical practice of medicine, health care delivery systems, utilization methods and treatment protocols required

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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