Sr. Medical Director, Utilization Rev/Med Pol

Position Summary:

Reporting to the Health Plan Chief Medical Officer, the Senior Medical Director for Utilization Review will be responsible for providing clinical leadership and subject matter expertise to both the Utilization Review function and Medical Policy function at CCA. This role is critical in helping the organization provide high quality, equitable care to our rapidly growing dually eligible and MAPD members. This position is responsible for providing medical oversight for physician utilization review and has a deep understanding of the available tool packages for utilization management (CMS guidelines, MassHealth guideline, McKesson Interqual, MCG Health's (Milliman) Care Guidelines). This position is also responsible for the creation and management of a robust set of evidence based medical policies and medical necessity guidelines. The ideal candidate will have experience with public programming, preferably with a D-SNP plan, MAPD and Medicaid and has excellent clinical judgement.

This position is expected to build relationships with leaders and staff across other CCA clinical departments and the broader CCA organization. This work entails collaborating cross-functionally to exchange clinical knowledge, achieve high quality member care, and improve processes. The Sr. Medical Director for Utilization Review and Medical Policy should be respected as a thought leader and subject matter expert within CCA and the industry. The role is expected to exercise a high degree of innovative thinking - regarding both member care and overall CCA operations.

Supervision Exercised:

Yes, which includes but is not limited to providing leadership, work direction, and performance feedback to subordinate staff.

Essential Duties & Responsibilities:

• Direct the activities of the department often through subordinate management or high-level individual contributors with responsibility for influencing strategic direction, planning, budgeting, policies, and business practices
• Oversees the physician review and medical policy function at the organization, working closely with other medical management team members; Collaborates with leaders and staff across the organization
• Exercises negotiation, persuasion, and advisory skills with high level individuals inside and outside the organization, including state and federal level regulators
• Leads continuous development and improvement of policies, protocols, clinical guidelines aligned with business practices and the utilization review function.
• Ensure compliance with medical policy and maintains compliance with all federal, state, and local regulatory guidelines
• Active participation in or leadership of clinical meetings, including but not limited to the Long-Term Support Services workgroup, Clinical Utilization Committee, and the Medical Policy Committee
• Participates in all required audit activities as appropriate
• Provides second level review of member appeals and quality of care concerns
• Documents all clinical work in a timely manner and provides the necessary documentation required for data collection and billing purposes.
• Performs daily medical reviews correspondence regarding review determinations, physician peer review activities and discusses specific clinical issues with providers and other staff, as necessary.
• Participates in all call responsibilities.
• Attends clinical team meetings and other mandatory educational sessions, as appropriate.
• Conducts educational and training activities that promote appropriate and effective patient care
• Provides educational updates to clinical staff.
• Participates in orienting and training new employees as required.
• Participates in quality assessment and quality improvement within CCA and supports plan accreditation as determined by Quality Management and Accreditation Team
• Seeks to maintain a constructive work environment and maintains effective communication with other employees and managers
• Participates in annual clinical team retreats and social / teambuilding events
• Maintains required professional credentialing and appropriate CME standards
• Attends external meetings and activities as a representative of the organization as requested
• Support teams and track Key Performance Indicators (KPI) related to clinical care for members via telehealth technologies (video, chat, etc.) for a clinically appropriate clinical care and care management services.
• Other responsibilities assigned by CMO of Health Plans

Secondary responsibilities:

• Plans and directs medical policies and programs
• Responsible for strategic clinical relationships with physicians

Working Conditions:

• Standard office conditions.
• Full-time remote (with occasional travel) available

Required Education (must have):

• MD, DO, or equivalent doctoral degree from an accredited institution

Required Licensing (must have):

• Active Massachusetts medical license
• Board Certified or Board Eligible in practice area
• Must be clear of any sanctions by the applicable state or Office of the Inspector General
• Must be eligible to participate in any federally or State funded healthcare programs

MA Health Enrollment (required if licensed in Massachusetts):

• Yes, this is required if the incumbent is licensed in Massachusetts.

Required Experience (must have):

• 2 or more years of full-time experience practicing medicine
• 3 or more years in a combination of the following: a) full time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO); b) Preferred Provider Organization (PPO), large Health Care organization, health plan or combination thereof
• Subject matter expertise in medical/utilization management review and health plan clinical operations
• Prior experience with Medical Policy Committee

Desired Experience (nice to have):

• 5 or more years of medical management and general management experience in a managed care environment
• 3 or more years in a combination of the following: b) Preferred Provider Organization (PPO), large Health Care organization, health plan or combination thereof
• Experience with quality improvement, monitoring and evaluation, health systems strengthening, innovation and training is desired, although not essential
• Primary care discipline

Required Knowledge, Skills & Abilities (must have):

• Proven skills, knowledge base and judgment necessary for independent clinical decision-making
• Excellent organizational, time-management and problem-solving skills
• Ability to function effectively as part of a multi-disciplinary team
• Excellent oral and written communication skills
• Strong interpersonal skills
• Commitment to social justice in medicine and an understanding of healthcare reform
• Effective teaching and mentorship skills
• Familiar with a variety of the field's concepts, practices, and procedures.
• Relies on extensive experience and judgment to plan and accomplish goals.
• Performs a variety of complex tasks.
• Ability to lead and direct the work of others.
• A wide degree of creativity and latitude is required.
• Acts ethically and raises concerns as needed

Required Language (must have):

• English