Oversee and direct the administration of clinical services for company. Recommend enhancements to current utilization management, quality of care, and clinical initiatives based on extensive knowledge of healthcare delivery systems, utilization strategies, reimbursement methods, and treatment protocols. Direct the development and administration of strategic departmental plans, including business, production, and organizational priorities. Execute business strategy to ensure programs and policies are aligned with the company's objectives.
ESSENTIAL JOB FUNCTIONS:
- Oversee the design and implementation of the organization's overarching quality strategy and related plans.
- Design and implement clinical quality and provider performance programs across the organization's delivery system. Provider programs will include, but not be limited to, specialists, primary care, hospitals, and integrated "Systems of Care." This work includes regular meetings with SOC providers to implement programs.
- Oversee organization participation in National Committee for Quality Assurance (NCQA) accreditation activities, and co-lead Centers for Medicare & Medicaid Services (CMS) 5 STAR clinical program.
- Chair the organization's Corporate Quality Governance programs, including the Quality and Medical Committees. Serve as the Quality liaison to the Board of Directors.
- Ensure compliance with all state, NCQA, and CMS rules, policies, and regulations.
- Partner with Network Management leadership to refine reimbursement policies. Ensure alignment, where applicable, to quality strategies, and direct implementation of those strategies with network providers.
- Oversee all Pharmacy programs from a medical perspective. Chair the Pharmacy & Therapeutics (P&T) Committee, as well as Specialty P&T Committee. Serve as physician liaison to PBM.
- Represent BCBSRI across key external Public Policy stakeholders, including, but not limited to, the Rhode Island Medical Society, Hospital Association of Rhode Island, Office of the Health Insurance Commissioner, Department of Health, and the BCBSRI Health Care Community Exchange Council. Serve as a trusted resource to the state of Rhode Island relative to public health, healthcare affordability, clinical quality, and delivery system reform.
- Advise Sales leadership in the design of reporting (Custom Account Profiles) for strategic BCBSRI employer accounts and, at times, serve as clinical expert and advisor to larger/key accounts.
- Perform other duties as assigned.
Minimum Education and Experience:
- Board-certified Doctor of Medicine in a primary care specialty with a current, unrestricted license to practice in Rhode Island.
- Five or more years of experience in private practice.
- Five or more years of management experience or experience leading a team.
Preferred Education, Additional Qualifications, and Experience:
- Knowledge of CMS Medicare Advantage regulations, NCQA and URAC standards, and RIDOH regulations.
- Knowledge of quality improvement principles and utilization improvement policies and methods to change provider behavior.
- Knowledge of finance and reimbursement methodologies.
Required Knowledge, Skills, and/or Abilities:
- Knowledge of managed benefits strategies, utilization review techniques, healthcare financing and delivery, and healthcare infrastructure design.
- Knowledge of health payer operations and applied experience in quality improvement technologies.
- Ability to collaborate while dealing with complex situations.
- Ability to think creatively and to drive innovation.
- Ability to motivate, lead, and inspire a diverse group to a common goal/solution with multiple stakeholders.
- Ability to convert business strategy into action-oriented objectives and measurable results.
- Ability to develop and manage a budget.
- Strong business acumen and political savvy.
- Strong leadership skills.
- Ability to mentor, coach, and provide guidance to others.
- Ability to act as a strategist, visionary, or change agent.