Massachusetts and Rhode Island Market Medical Director

4 weeks ago

Boston, United States Commonwealth Care Alliance Full time

Reporting to the Health Plan Chief Medical Officer (CMO), the Massachusetts and Rhode Island Market Medical Director is an integral part of a mission-driven clinical and market team.

The Medical Director's primary responsibilities are to ensure that the clinical processes that contribute to the Massachusetts Duals (SCO/OneCare) and RI DSNP, & MA/RI MAPD health plans are high functioning and medically appropriate, including care management, health plan operations, quality improvement, and HEDIS. The incumbent will also contribute to network strategy, working with providers on behalf of members and the health plan to ensure best in class outcomes through aligned value-oriented relationships.

This is a hybrid role with in-person engagement in Massachusetts and Rhode Island.

1) Works collaboratively with leadership at CCA Health to achieve strategic goals for the MA & RI products as relate to the development and implementation of population health and quality improvement strategies, with an emphasis on HEDIS metrics and health equity.

2) Works with the enterprise clinical leadership team to operate consistent and efficient care management programs, metrics, and reports, including both delegated and non-delegated programs.

3) In collaboration with their supervisor and Market General Manager, works with external stakeholders including network providers and facilities to design models that improve care coordination, care delivery, metrics, outcomes, and accurate HCC coding for value-based contracts. Identifies cost drivers and works with network providers on management of unplanned care and cost variances.

4) Provides medical leadership, consultation, oversight, and education to clinical teams, including implementing clinical education for both APCs and non-prescribing team members. Supervises advance practice clinicians as needed.

5) With clinical, quality and BH leadership, creates and implements programs that improve the health of the senior dual eligible and MAPD population, including for dementia, chronic disease management, and depression.

6) Collaborates with pharmacy on related medication issues such as formulary development, medication adherence, opioid and other high-risk medication use.

7) Contribute to Medical Expense Management, including providing recommendations and working closely regarding implementation.

8) Understands contractual requirements, supports procurement efforts, and participates in health plan audits as appropriate.

9) Represents CCA at external meetings and conferences as requested and acts as a clinical ambassador in creating new market relationships.

10) Strategic contribution and oversight as appropriate of committees (including but not limited to credentialing committee activities, utilization management reviews, medical policy committee)

11) Other duties as requested.

Required:

* MD/MO Degree
* MPH,MBA, or MHA welcome, but not essential
* Board Certified Geriatrician
* Experienced with community and long term institutional care
* Has or can obtain an unrestricted license in the state of employment
* 5+ years of clinical experience
* 2+ years working in a health plan
* Experience working in and ability to collaborate effectively as part of interdisciplinary team with clinical and non-clinical staff.
* Experience creating cohort-specific care paths and executing on population health strategies
* Interest and experience in serving patients with complex medical, behavioral, and social needs
* Strong interpersonal skills; communication and presentation skills; analytic skills; teaching and mentorship skills; organizational and time-management skills
* Creative problem solver
* Commitment to social justice in medicine and an understanding of healthcare reform
* Ability to lead by influence and work independently
* Excellent clinical judgement and clinical decision making skills

Preferred:

* Perfer primary care field
* Fellowship in Geriatrics or Hospice and Palliative Medicine
* Expert knowledge of public payer health care programs (Medicare, Medicaid)
* Expert knowledge of provider reimbursement strategies, including an understanding of value-based models
* Experience with quality improvement, monitoring and evaluation
* Knowledge and successful track record of health plan operations including utilization and care management, claims processing, contracting and provider relations and regulatory compliance.

Languages: English Required; Bilingual Spanish or other language Preferred

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