Medical Director Clinical Programs

4 weeks ago

Louisville, United States Elevance Health Full time

This is a remote, individual contributor role and the person in this position must live within 50 miles of an Elevance Health location. Work schedule: Monday - Friday, standard business hours.

The Medical Director Clinical Programs is responsible for designing and implementing clinical programs with specific medical condition focus for all lines of business enterprise wide. Analyzes and interprets data in collaboration with data and analytics to identify opportunities. Partners with LOB (line of business) and Market leaders to ensure clinical solutions align with membership health priorities. Collaborates with payment innovation on clinical programs that support providers in value-based payment arrangements. Serves as a subject matter expert/collaborator with LOB, market leaders, and other clinical initiatives including cost of care. The role is 50% UM support and 50% working on West Region Star related work.

Primary duties may include, but are not limited to:

  • Designs and develops national level interventions leveraging existing tools that will drive performance in value-based care in support of the innovation and execution of corporate clinical interventions.
  • Provides clinical expertise, captures and shares best practices across regions to provider partners as well as the company’s medical directors by way of studying designs, analytics and reporting for clinical quality that drives improved healthcare outcomes.
  • Provides an end-to-end clinical solution by taking a problem from initiation to execution with reporting and analytics as an outcome.
  • Accountable for achieving performance results in value-based care by engaging, influencing and supporting physicians.
  • Engages with providers in joint operating committees and builds relationships with clinical leadership of provider collaboration groups.
  • Promotes clinical best practice sharing across all lines of business to improve results and drive efficiency and effectiveness.
  • Works to develop and deliver high impact interventions, supporting content development and practice transformation embedded capabilities to significantly improve provider performance that drive cost of care and improve HEDIS/Stars where applicable.

Minimum Requirements:

  • Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
  • Must possess an active unrestricted medical license to practice medicine or a health profession.
  • Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.
  • Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

  • California licensed preferred.
  • Consulting experience and/or MBA
  • Experience with Medicare Advantage STARS or Risk Adjustment
  • Six Sigma or formal process improvement experience preferred.
  • Analytical experience in creating study designs, ROIs and statistical techniques preferred.
  • Advanced knowledge in health care systems and health policy, quality measures, performance measurement, and quality improvement, and the clinical understanding for clinical quality programs strongly preferred.

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