Director of Medical Reviews

Healthfirst

Director of Medical Reviews leading medical necessity assessments and overseeing quality initiatives within a leading not-for-profit health insurer. Collaborating with clinical teams to ensure compliance and operational efficiency.

Posted 4/15/2026full-timeRemote • Connecticut, New Jersey, New York • 🇺🇸 United StatesLead💰 $154,600 - $236,555 per yearWebsite

About the role

Key responsibilities & impact

Conducting medical necessity reviews in the context of utilization management and appeals
Assess/review requests for authorization, and claims payment
Collaborate with Utilization Management and Care Management and medical departments as needed
Maintain productivity standards
Complete mandatory Company compliance training

Requirements

What you’ll need

Licensed M.D. or D.O.
Board Certified in a specialty recognized by the American Board of Medical Specialties
Board Certified in Internal Medicine, Family Practice, OBGYN or Emergency Medicine
Previous, relevant experience in utilization management and clinical practice
Knowledge of Medicare, Medicaid, and MLTC plans
5 years clinical experience

Benefits

Comp & perks

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical necessity reviewsutilization managementclaims paymentauthorization requestsclinical practice

Soft Skills

collaborationproductivity standards

Certifications

Licensed M.D.Licensed D.O.Board CertifiedAmerican Board of Medical Specialties