Senior Medical Director - Medicaid

About the Role

Under the direction of the CMO, this position is responsible for medical management and key leadership functions that support Medicaid strategic initiatives. The Medical Director helps direct medical operations for the product and supports the development of reliable, innovative clinical processes, analytics, and product solutions that produce excellent results for members and the plan. In this role, the Medical Director will work collaboratively with product leaders to oversee operational and financial goals and drive improvements that address complex trends in quality, care management, and provider relations. The position will serve as a role model in upholding the values, business objectives, and service expectations of the UPMC Insurance Division.

The Medical Director will supervise medical staff assigned to these products and work closely with Product and all other areas of clinical and operational leadership.

Responsibilities

• Stay current on innovative care delivery models and trends; gather, adapt, and apply market intelligence to inform the design of Health Plan products, programs, and business opportunities.
• Leverage technology to optimize product and program performance, member engagement, and member benefit.
• Collaboratively support and develop strategic, tactical, and financial plans to optimize Medicaid product and quality performance and member experience; support continued product growth and development while ensuring beneficiaries’ needs are well served, with a strong emphasis on quality and value.
• Develop and lead initiatives for the Medicaid plan in collaboration with other leaders.
• Develop and direct clinical strategies to improve quality and financial results for the Medicaid product.
• Align Medicaid products with new and emerging regulatory requirements and policies.
• Represent the Medicaid product and Health Plan in public settings, as needed.
• Establish, create, and maintain institutional working knowledge on Value-Based Programs, Pay-for-Performance designs, and other specific product line initiatives.
• Partner with other Medicaid leaders to establish operational and financial goals for products and programs; actively monitor trends and manage performance against those goals.
• Define and drive the implementation of analytics and information systems to manage and report on Medicaid products and chronic care programs.
• Develop and maintain effective internal relationships with key stakeholders, including network providers, community organizations, DHS, and other government organizations.
• Actively participate in oversight of the Enhanced Member Support Unit (EMSU), Quality Management (QM) Department, and Utilization Management (UM) Department, including determinations of service or benefit medical necessity and appropriateness, and continued inpatient stays beyond approved days, according to established criteria.
• Collaborate with departments to support clinical, operational, and strategic goals and provide timely medical decisions, including after-hours consultation, as needed.
• Collaborate on the review of annual budget discussions with DHS.
• Serve as liaison and be accountable to the governing body and Quality Management Committee for all QM, UM, and QI activities and initiatives.
• Be available to the PH-MCO's medical staff for consultation on referrals, denials, complaints, and problems.
• Be directly involved in the PH-MCO's recruiting and credentialing activities.
• Be familiar with local standards of medical practice and nationally accepted standards of practice.
• Have knowledge of due process procedures for resolving issues between participating providers and the PH-MCO administration, including those related to medical decision-making and utilization review.
• Be available to review, advise, and take action on questionable hospital admissions, medically necessary days, and all other medical care and medical cost issues.
• Be directly involved in the PH-MCO's process for prior authorizing or denying services and be available to interact with providers on denied authorizations.
• Have knowledge of current peer review standards and techniques, and risk management standards.
• Oversee and be accountable for all Quality Management, Utilization Management, and Quality Improvement activities.
• Oversee referrals to the Department and appropriate agencies for cases involving quality of care that have adverse effects or outcomes.
• Oversee the processes for potential fraud and abuse investigation, review, sanctioning, and referral to the appropriate oversight agencies.
• Define and manage resources, including Medical Directors and other clinical staff, to achieve strategic and operational goals for Medicaid initiatives.
• Develop and mentor physicians and other managers as effective leaders, promoting high engagement.
• Serve as an executive role model for UPMC’s core values and mission.
• Work with medical, nursing, and operations leaders to advance UPMC’s capabilities in chronic care program development.
• Assist with the development of a clinical organization that prioritizes the retrieval and intuitive interpretation and evaluation of statistics and medical trends to establish aggressive preventative health targets and objectives.
• Serve on physician committees and work with each Health Management program to monitor, assess, and ensure the program's clinical success.
• Establish best practices for care programs including Diabetes, Asthma, Congestive Heart Failure, End-Stage Renal Disease, and Maternity Programs.
• Create progressive physician group and provider education programs; direct concurrent education and communication related to credentialing, UM, and QI.
• Be responsible for the Technical Assessment Committee (TAC).
• Establish and implement superior performance standards while maintaining compliance with applicable statutes, rules and regulations, the standards of accrediting bodies, and corporate policies and compliance program standards.
• Collaborate with VP, Medical Affairs to engage all functional areas of the Health Plan from a clinical perspective to develop innovative programs and product lines; serve as the primary clinical liaison with Network Services, Strategic and Advisory Services, Finance and Underwriting, Operations, Information Systems, Pharmacy, and Product Development.
• Serve as an integral part in the design and implementation of medical management initiatives such as disease management to improve quality and cost-effectiveness of care delivered to Commercial, Medicare, and Medicaid members.
• Swiftly respond to challenges and/or opportunities as they arise.
• Develop and implement innovative programs to act on historical data, identifying new trends, retooling existing approaches, and analyzing the competition.
• Collaborate with physicians to develop clinical programming by accessing and mining clinical data, devising methods to manage populations.
• Partner with physicians to improve reimbursement models and performance-based physician incentive programs.
• Collaborate with Vice President, Medical Affairs, and Health Plan senior leadership in the development of short-term, mid-term, and long-range strategic planning for the Health Plan.
• Partner with physician leaders, and hospital and business executives to exceed clinical, operating, financial, quality, and market share objectives.
• Deliver executive-level presentations for UPMC senior management and other designated groups.
• Lead the Utilization Management organization, Pod functions, as well as Quality of Care; lead management of 2nd level grievances, guide and manage the most complex cases, appeals, quality regulatory requirements, credentialing, troubleshooting, and special investigations.
• Serve as a 'role model' and 'health advocate' within the Western Pennsylvania community, including active participation with UPMC-sponsored activities, public events, and community outreach programs.
• Provide clinical leadership and support for the Quality Improvement program, including study design for NCQA accreditation initiatives, coordination of HEDIS reporting, and meeting or exceeding all regulatory requirements.
• Serve as Clinical Leader for the UPMC for Life Medicare program.
• Identify opportunities to further integrate information systems and departmental interface capabilities, and from a clinical perspective, assist in affecting the 'phase-in' of newly acquired OAO interactive software.
• Directly participate in the oversight of the QM Department and the UM Department.
• Participate in the creation of opportunities to consult, interact, and elicit feedback with the physician community, then act upon this valuable information, raising proactive clinical intervention to unprecedented levels.
• Nurture personal and professional growth/development by attending seminars, workshops, and establishing professional affiliations to keep abreast of the latest trends in the field of expertise.
• Ensure continuous improvement strategies are established and implemented for Health Management outcomes and processes, encouraging a culture that initiates intensive and persistent case management for members.
• Influence medical cost trends in partnership with network services and the medical management team, including the development of trend-specific initiatives, provider fee schedule review, and identification of medical management best practices.
• Create opportunities to integrate pharmaceutical and medical strategy with innovative solutions.
• Interface with UPMC Health System cross-functional and shared resources to further the 'cause' to create a seamless healthcare patient-flow management process and insurance model.
• Motivate and mentor UPMC Health Plan's clinical Medical Affairs staff by 'setting the pace' and fostering 'excellence by example'.
• Assess the overall team, including ongoing recruitment and hiring of talent. Ensure that the organization has the 'right people' in the 'right positions' and that the organization's structure is designed to maximize results.
• Collaborate with the VP, Medical Affairs, and Chief Medical Officer to develop unique partnerships and differentiated relationships with current and prospective employer groups, consultants, and brokers, to understand and meet their health and welfare needs.
• Passionately manage UPMC Health Plan's clinical Medical Affairs organization for Commercial, Medicare, and Medicaid lines of business, including leading, educating, and mentoring Medical Directors, and managing all clinical aspects of Medical Management, Quality, Health Management, Utilization Management, Disease Management, Strategic Planning, and Policy.

Requirements

• Doctor of Medicine or Doctor of Osteopathy from an accredited school.
• Unrestricted License in Pennsylvania.
• Post-residency clinical experience.
• Minimum ten years of clinical experience preferred.
• Clinical experience in geriatrics or other disabled populations preferred.
• At least ten years of management experience preferred.
• Experience in a managed care setting preferred.
• Ability to implement medical policies and enforce those policies through appropriate action.
• Ability to maintain effective professional liaison with all levels of executive and medical staff, including professional and institutional providers of care.