Job Overview
Location
Remote
Job Type
Full-time
Category
Human Resources
Date Posted
March 31, 2026
Full Job Description
📋 Description
- • Conduct medical necessity reviews for utilization management and appeals processes
- • Develop and implement quality improvement initiatives based on clinical data analysis
- • Collaborate with utilization management, care management, and medical departments to review cases and manage caseload
- • Design reports, analyze trends, and establish policies to ensure high-quality, efficient programs
- • Attend meetings with other Executive and Senior Medical Directors
- • Demonstrate flexibility in response to changing case load volumes and leadership requests
- • Complete mandatory company compliance training for new systems and software
- • Participate in peer-to-peer discussions with provider organizations
- • Perform other duties as assigned
- • Provide weekend coverage as needed
🎯 Requirements
- • Licensed M.D. or D.O.
- • Board Certified in a specialty recognized by the American Board of Medical Specialties
- • Previous relevant experience in utilization management and clinical practice
- • Knowledge of Medicare, Medicaid, and MLTC plans
- • Time management, critical thinking, communication, and critical thinking skills
- • Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
- • Knowledge of member satisfaction/incident management and regulations
- • Knowledge of quality improvement methodologies
🏖️ Benefits
- • Medical, dental, and vision coverage
- • Incentive and recognition programs
- • Life insurance
- • 401(k) contributions
Skills & Technologies
About Healthfirst, Inc.
Healthfirst is a New York-based health insurance provider offering affordable, comprehensive plans to individuals, families, and seniors. For over 30 years, the company has delivered diverse options, including Essential Plans, Medicaid Managed Care, Child Health Plus, Marketplace plans, and specialized Medicare Advantage and Long-Term Care solutions. Healthfirst offers benefits like medical, prescription drug, dental, and vision coverage. Notably, Healthfirst maintains the only 5-star rated Essential Plan in New York for two consecutive years, solidifying its position as a trusted leader in accessible community healthcare.
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