Medical Director, Medicare
2 weeks ago
**Medical Director, Medicare**
Location: Remote, United States
Primary Job Function: Medical Management
ID**: 31514
Your career starts now. We are looking for the next generation of health care leaders.
At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
**Responsibilities:**
The Medical Director, Medicare (MDM) provides organizational leadership in the Population Health (PH) Medicare Line of Business (LOB) under the direction of the Medicare (MC) CMO, in areas such as care management, utilization management/medical cost, quality results, provider performance and policy, to advance ACFC and Medicare Plan objectives and improve the health of our member population.The MDM serves as the lead physician to guide care management, define, and achieve quality outcomes, manages day-to-day aspects of PH Medicare functions, and acts as a subject matter expert to other areas. The Medical Director is the physician responsible for the overall care and required activities supporting the enrolled population and Plan, applying clinical and administrative skills to guide care and quality initiatives/performance, coordinating with stakeholders, and aligning with providers.
Responsibilities include:
+ Oversight of MC utilization (UM), trend management, and implementation of strategies to ensure appropriate, cost-effective, efficient care. Assisting in review and implementation of UM and medical policy, including recommendations for improvements to enhance efficiency.
+ Provides leadership to address MLR and utilization. Offers strategies or ideas for new initiatives and supports implementation of value initiatives (HVOs). Reviews trends and offers insights, making data-driven decisions.
+ Works in collaboration with UM and Care Management (CM) to understand utilization of services and develop and implement programs to address inappropriate utilization, readmissions, and achieve MLR.
+ Physician leader for quality management functions. Analyzes information to develop interventions that improve quality of care and outcomes, with a focus on at risk performance (ex: STARS, State-based programs, VBC, MOC). Supports quality through QAPIC, QIS/QIPs, and incentive programs.
+ Tracks, monitors, and meets the annual goals and key performance indicators of PH and LOB.
+ Supports and upholds regulatory requirements, compliance, policies and contractual agreements, and addresses/mitigates risk. Knowledgeable on policies that impact members and physician networks, state mandates or other requirements in contract with clinical, operational, and financial impact
+ Renders medical management decisions that are member-centered and support PH goals, addressing clinical and non-clinical needs including health equity, in medical reviews, rounds, quality of care concerns, provider concerns, grievances, and other areas. Provides clinical guidance to CM including MOC, member case reviews as needed and as required in MMP, DSNP and LTSS. Documents and pre-reviews plans.
+ Works within the Plan and network providers on value-based initiatives, quality, and provider satisfaction, building market relationships. Supports providers to align performance.
+ Supports new market entry and implementations, LTSS alignment and benefits coordination.
+ Supports MC CMO needs and assignments as directed; other duties as assigned.
**Education/Experience:**
+ A medical degree (M.D. or D.O.).
+ Valid, active and unrestricted medical license; must obtain licensure in all Medicare markets upon hire.
+ Active Board certification in Family Medicine, Internal Medicine, or Geriatrics.
+ Must be clear of any sanctions by the applicable state or Office of the Inspector General.
+ Must not be prohibited from participating in any Federally or State funded healthcare programs.
+ 3+ years of full-time equivalent leadership experience in a managed care/Health Plan, Medicare program, or large Health Care Organization, with direct experience in UM, CM, quality, and clinical programs.
+ 3+ years of full-time experience practicing clinical medicine. Experience in and use of best practices, clinical guidelines, and evidence based care.
+ Deep understanding of healthcare systems, providers, health insurance drivers.
+ Outcome and member focused, excellent team leadership and communication skills.
+ Mission-guided, passion for helping members.
+ Demonstrated healthcare improvement and change management success.
+ Works effectively in teams; leads and manages meetings; builds trust and rapport,; interdisciplinary contributions.
**Diversity, Equity, and Inclusion**
At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
We keep our associates happy so they can focus on keeping our members healthy.
**Our Comprehensive Benefits Package**
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.
EOE Minorities/Females/Protected Veterans/Disabled
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