AVP - Medical Director for Complex Care

1 week ago

New York, United States Healthfirst Full time

Description and Requirements

The AVP, Medical Director for Complex Care is responsible for providing clinical leadership over care management of complex and catastrophic care members. The Medical Director will lead daily interdisciplinary discussions about medically complex/catastrophic care members to help identify the appropriate health plan actions to improve care and lower costs. The Medical Director may also be responsible for other medical management programs and projects as assigned, including Utilization Management (UM), Care Management (CM), Credentialing, Appeals/Grievances Management (A&G), Quality Assurance/Improvement (QA/QI) and Delegation Oversight. This includes supporting the development and implementation of policies and procedures for HFNY that meet all regulatory requirements for managed care clinical programs. This position reports to the Vice President/Senior Medical Director but works closely day-to-day with the Vice President of Clinical Management.

Duties and Responsibilities:

• Provide day-to-day oversight and leadership of the Complex/Catastrophic Care Interdisciplinary team

• Provide clinical leadership of the multi-disciplinary rounding process, as well as care management rounds and peer-to-peer discussions with health systems, vendors and other internal and external collaborators.

• Participate in the development and implementation of new or updated formal policy and procedures for UM, CM, Credentialing, Delegation and QA/QI

• Collaborate with other business leaders in the design of workflows and job aides developed to implement designated policies (see above). This includes participating in the design and execution of training plans for clinical staff, lay staff, and peer review professionals.

• Serve as a voting member (as assigned) on Credentialing, QI/QA, UM, CM, A&G and Delegation Committees/Subcommittees acting as an expert clinical leader. Collaborate with business owners to implement any new policies or directives from these committees.

• When needed, manage peer review and clinical case review activities for UM, CM and A&G using approved policies and procedures within designated workflows to provide specific clinical insight and decision making on specific cases. This includes maintaining all regulatory requirements for timely and complete decision making.

• Interact and interface (via face-to-face, telephone or email) with physicians, hospitals and other health care providers as required to support the policies and procedures of HF.

• Collaborate with business leaders in internal and external audit activities including preparation and participation. This includes the management of audit activities for peer review professionals.

• Additional duties as needed

Minimum Qualifications:

• Graduate of MD/DO program with valid license

• Experience overseeing or working directly with plan-based care management teams

Preferred Qualifications:

• Board Certified in Internal Medicine or Family Practice

• Analysis of Quality and Utilization Data for use in clinical programs

• Experience with public speaking, public communication, and training others

• Experience using CM/UM software and electronic medical records

• Clinical experience with direct care of patients in ambulatory and inpatient setting

• Experience with administrative aspects of health care in a hospital, a managed care plan or a large multispecialty clinic such as developing policy and then implementing and supporting procedures for credentialing, QI/QA, UM, CM, Delegation and A&G.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

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