CMO, Utilization Management and Medical Policy

UPMC Senior Communities • $210K — $250K *
Pittsburgh, PA 15237In-Person
Healthcare
11 - 15 years of experience
Today
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Job Overview by Ladders

Qualifications

  • MD or DO degree and Pennsylvania medical license required.
  • Master's degree in business or health-related field preferred.
  • 15+ years of experience with 10 in a senior management role in managed care.
  • 5 years of experience in health care delivery systems management within managed care.
  • Strong background in Quality Improvement and Utilization, with finance and statistical analysis knowledge.
  • Proficient interpersonal skills with strong analytical, communication, and problem-solving capabilities.

Responsibilities

  • Provide clinical and operational expertise to senior management.
  • Manage ongoing clinical evaluation of assigned business lines.
  • Oversee development and evaluation of clinical resource management programs.
  • Standardize practice patterns and achieve desired outcomes through benchmarking.
  • Supervise Medical Policy team for timely and evidence-based policy implementation.
  • Ensure compliance with regulations and consistent utilization management practices.
  • Support provider relations and guide Medical Directors toward quality care benchmarks.

Benefits

  • Comprehensive health and wellness programs.
  • Support for professional development and continuing education.
  • Flexible work arrangements and work-life balance initiatives.
  • Opportunity to lead innovative healthcare initiatives.
  • Engagement in meaningful community health efforts.
Full Job Description
Purpose:
Under the administrative direction of the UPMC Insurance Services Division Chief Medical Officer, this senior leader will serve as a strategic, collaborative business partner and is responsible for medical leadership in the clinical and quality strategies and operations for the ISD's medical management, including oversight of all physician utilization management and medical policy teams. This position will also serve as the lead physician for all commercial products. In addition, this position will engage whenever indicated with IDFS clinical partners and will be the clinical leader in our provider benchmarking activities.This position will oversee the management of physicians, will collaborate with other clinical leadership to insure the development, implementation and appropriate coverage of effective services, will serve as the authority on medical issues and is responsible for compliance with all clinical medical policies, directives, rules, regulations and clinical performance standards related to the identified lines of business, including all relevant accreditation and state and federal government regulations and all accrediting bodies for all lines of business, under the direction of the CMO. This senior leader is accountable for ensuring the membership receives exceptional service and that clinical outcomes meet or exceed all standards or benchmarks. He/she assures best standards of practice and promotes person centered, recovery-focused care models and policies within the division working with internal and external stakeholders to represent an integrated approach to health. This leader also promotes cost-effective practice patterns through appropriate interventions with health care providers while meeting or exceeding the expectations of internal and external customers by utilizing first-hand member and scientific data for continual improvements for products and services. This position will directly interact with physicians, hospitals, and physician practices.

Responsibilities:

  • Contribute clinical and operational expertise to Division CMO, CEO and all senior management activities at the Insurance Services Division.
  • Manage the development, implementation, and provision of ongoing clinical evaluation of the lines of business as assigned.
  • Oversee the development, implementation and ongoing evaluation of clinical resource management programs and community-based programs.
  • Oversee the standardization of practice patterns and the achievement of desired outcomes through clinical resource management and provider benchmarking.
  • Oversee and supervise the Medical Policy team to insure timely, evidence-based, data-driven development and implementation of appropriate medical policies, both pre-service and post-service, to ensure the members receive coverage for clinically appropriate services in the most cost effective level of care.
  • Oversee the physician Medical Director team to ensure compliance with all regulatory requirements, appropriate interpretation of medical policies, consistent implementation of utilization management criteria across all lines and collaboration across the IDFS as well as other network and non-network facilities.
  • Provide support of the provider relations activity of the lines of business as assigned. Supervise and guide the Medical Directors in identified lines of business in regards to meeting and exceeding standards or benchmarks for quality care and establish benchmarks or standards as needed.
  • Represent UPMC Insurance Services Division at various internal and external meetings/conferences.
  • Develop and cultivate strong working relationships with regulatory entities.
  • Participate in the strategic planning of the UPMC Insurance Services Division.
  • Exemplify a collaborative approach to work ethic for staff to model.
  • Establish and monitor the appropriate budget as assigned. Select, retain, develop, and reward a competent staff.
  • Develop strategies to foster external relationships (including state and federal agencies)
  • Recommend annual plan along with the strategies, tactics and resources necessary to achieve division goals and objectives directly related to the essential functions of the position.


Qualifications:

  • MD or DO degree and Pennsylvania medical license required.
  • Master's degree in business or health related field preferred.
  • 15+ years' experience with 10 in a senior management role with behavioral service delivery of managed care system
  • Senior level manager with at least five years of experience in health care delivery systems management in a managed care environment.
  • Strong QI and Utilization background with a working knowledge of finance, management information systems, and statistical analysis.
  • Must demonstrate competency in interpersonal skills and political savvy, analytical, communication, and problem-solving skills, clinical proficiency, team and customer service orientation, the ability to deal with ambiguity and out of the box thinking.
  • Must possess the ability to interact on an academic as well as community based level.
  • Knowledge and experience with regulatory requirements for delivery of health plan products including commercial, government products.
    Licensure, Certifications, and Clearances:

About UPMC Senior Communities

UPMC Senior Communities Careers

There has never been a better time to explore the diverse job opportunities at UPMC Senior Communities—the leading network of senior living facilities focused on innovative care and professional excellence.

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Join UPMC Senior Communities to assist in transforming the experience of aging through top-tier care and wellness programs. This is an opportunity to be part of a team that values leadership, diversity, and innovation in the healthcare sector. Lead in a unique role where skills in healthcare, empathy, and leadership converge to enhance the lives of seniors. UPMC Senior Communities stands at the forefront of the industry, integrating advanced technology and personalized care practices. Engage with a professional network of healthcare providers and administrators dedicated to pioneering improvements in senior living. Collaborate with over 3,000 dedicated professionals across various facilities.

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Be part of a culture that thrives on innovation and continuous improvement. UPMC Senior Communities employs a vast array of healthcare professionals and support staff, all dedicated to setting new standards in senior care.

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Deliver targeted solutions and personalized care that significantly improve the quality of life for residents. UPMC Senior Communities offers a platform for professionals to apply their expertise in a meaningful and impactful way.

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Work alongside a team that values compassion and professionalism, harnessing the collective capabilities to deliver exceptional care. UPMC Senior Communities promotes a collaborative environment where every team member’s contribution is valued.

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Advance your career within UPMC Senior Communities through a variety of pathways, from direct care positions to administrative roles. Enjoy robust benefits, professional development programs, and a supportive work environment that encourages long-term career growth.

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