Position SummaryThe VP Medical Director of Clinical Programs will manage the Health Plan Medical Directors and, as a Medical Director team, provide clinical support for the Health Management Utilization Management, Care Management and Quality teams. This VP will drive the development, promotion and delivery of high quality, evidence-based utilization and care management programs and processes. The VP will lead programs and reviews to support effective medical expense management, medical quality programs and outcomes, and programs to manage medical utilization trends such as inpatient, Emergency Department, Site of Care, pharmacy and radiology.
Job DescriptionPRIMARY DUTIES AND RESPONSIBILITIESEmployees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.
- Achieves defined clinical outcomes, affordability goals and growth targets, in partnership with HP SLT, to accomplish HP strategy, quality and cost containment
- Works closely across the HP to ensure compliance with government program regulations, including management of clinical appeals and grievances with sound clinical evidence and advice
- Works closely with the Medical Directors and the Director of Medical Economics to devise analytic approaches that support and measure strategic development and sound clinical programs
- Provides clinical insight into data to assist in development of and measurement of tailored interventions that address clinical trends and opportunities
- Develops key strategies to address opportunities in medical expense management
- Identifies opportunities for improvement in the quality of care that create competitive advantage for Martin's Point as it relates to the health of populations served
- Accountable for appropriate Utilization Management processes including sound partnership and collaboration between the UM/CM team and the Medical Directors to ensure High performance of team members that drive the right services at the right place and time for our health plan members
- Assists and provides clinical input into the evolution of care/utilization management, quality, and pharmacy related programs
- Contributes to and advises in product design and the Medicare bid processes
- Contributes to and advises in areas of clinical integration as it relates to risk adjustment
- Serves as a central HP leader aligning medical, clinical, and operational functions to achieve seamless and thorough solutions related to Medical and Payment Policies
- Actively engages with quality, network, and compliance teams to help drive performance
- In collaboration with the MPHC Chief Medical Officer (CMO), advocates with government/state regulatory entities, professional and medical society chapters, federal regulators/contactors, and as part of external communications and media relations to advance HP's clinical value story, evidence-based medical policies, and member health
- Provides subject/specialty-based clinical expertise and leadership to Clinical Programs and other areas of MHPC, as needed
- Assists the Market Medical Director for building and deepening relationships with area hospitals, physicians, and other health care providers in support of the Quadruple Aim
- Assists in creating a cohesive, network engagement strategy and reporting capability that supports iterative improvements in performance to population health and care management goals that are specifically tied to contractual agreements
POSITION QUALIFICATIONSEducation - Medical Degree (MD or DO) from accredited medical school
Licensure/certification- Board Certification in relevant discipline or specialty
Experience - 10+ years of experience to include several years of clinical practice, including a leadership role and Health Plan experience as a Medical Director
- HMO/Managed Care experience, including Utilization and/or Quality Program management and exposure to peer review, case management, population health, appeals, chronic and complex disease management, HEDIS reporting, and provider relations
- Experience with STARS and RAF in a Health Plan space preferred
- Government sector experience preferred (Medicare, Medicaid and or Military/Tricare products)
- Prior Management experience preferred
Knowledge - Deep knowledge and practical understanding of healthcare systems and managed care concepts
- Knowledge of performance-based HP/provider arrangements.
Skills - Excellent interpersonal communication and problem-solving skills
- Proficient with Microsoft Office applications (Outlook, Word, Excel, PowerPoint)
- Strong communication and presentation skills
- Proven presentation skills for both clinical and non-clinical audiences
- Strong analytic skills with proven understanding of health care utilization data and analytics
Abilities- Ability to influence in executive settings
- Ability to tailor message to a variety of audience levels
- Able to make data-driven decisions, implement solutions and document measurable impact. Data skills include the ability to design tracking reports for clinical and financial metrics
- ability to develop relationships with network and community physicians and other providers
- Demonstrates an understanding of and alignment with Martin's Point Values.
- Able to educate and promote best practices within medical and clinical care programs
- Able to lead, develop and manage a physician team
This position is not eligible for immigration sponsorship.Do you have a question about careers at Martin's Point Health Care? Contact us at:
[email protected] 
