Associate Medical Director, OLTSS

Overview:
The Associate Medical Director (AMD) for MassHealth’s Office of Long Term Services & Supports (OLTSS), under the direction of the Director of the Office of Clinical Affairs (OCA) or designee, is responsible for providing clinical expertise to OCA and to the MassHealth program staff in the areas of LTSS. MassHealth, the Commonwealth of Massachusetts’ Medicaid and Children's Health Insurance Program (CHIP) Program, through its Office of LTSS (OLTSS) provides coverage for a robust broad system of care for members of all ages who need long-term care services to enable them to live with independence and dignity in their daily lives, participate in their communities, and increase their overall quality of life. The AMD will serve as a clinical leader and resource for OCA and EOHHS programs and MassHealth providers to deliver optimal value by improving the quality, efficiency, effectiveness, and appropriateness anchored on the principles of independent living and person-centered care delivered to MassHealth members. The AMD will serve as a thought leader on population health management and the integrated health model, with an eye towards system-wide value enhancements by implementing best practices and technological solutions or other service delivery interventions.

Responsibilities:
Quality & Performance Management
Serve as a clinical lead in MassHealth LTSS quality, affordability and patient experience performance improvement efforts.

 

• Assist the Director of OCA or designee, and the Chief of MassHealth OLTSS by providing clinical input and leadership in the development, implementation, and overall performance management of clinical policy and quality strategy for MassHealth’s LTSS initiatives, including Dual Integrated Care Programs One Care, SCO, and PACE.
• Strengthen collaboration with Managed Care Entities (MCE) to optimize the quality of care, member experience, affordability and overall performance for MassHealth members attributed to One Care, SCO and PACE.
• Participate in OCA activities to monitor, report upon, and make recommendations regarding equity, quality, clinical and cost-effectiveness of MassHealth programs, including quality assurance and critical incident reviews for all LTSS programs, including integrated care management programs and related performance improvement initiatives, and provide recommendations to programs managers in designing and operationalizing program improvements.
• Engage with internal and external stakeholders, including by:
o Serving as a clinical liaison for MassHealth and MCEs, maintaining open channels of communication, educating on MassHealth policies and programs and supporting performance management efforts;
o Partnering with other EOHSS agencies and programs to improve cross-agency alignment with the goal of delivering an optimal integrated care experience for MassHealth members enrolled in SCO, One Care and PACE;
o Collaborating with external organizations serving MassHealth members enrolled in SCO, One Care and PACE, such as Independent Living Centers (ILCs), ASAPs, and other LTSS providers.
• Participate in or lead committees and meetings to enhance performance improvement and other OCA, EOHHS, and MassHealth meetings as designated by OCA Director or his/her designee.

 

Clinical Strategy, Policy, and Programs
Serve as a clinical subject matter expert in policy and program development for SCO, One Care and PACE.

 

• Provide clinical support, subject matter expertise, and clinical leadership to MassHealth OLTSS and OCA.
• Provide clinical consultation and guidance to integrated care program/contract managers and on clinically complex cases.
• Support LTSS Programs in reviewing clinical specifications for covered services.
• Provide clinical leadership to the activities of medical program managers.
• Provide updates and consult with OCA and MassHealth staff on new technologies, service delivery innovations, treatment methodologies, and policies.
• Provide clinical leadership and support for the development and implementation of MassHealth population health and health equity programming
• Participate in communications with MassHealth medical providers, conduct peer-to-peer discussions, as applicable, and educate physicians and others on current policy.Partner with other program leads (including the Chief of Payment and Care Delivery Innovation (PCDI), Chief of Office of Behavioral Health, Chief Pharmacy Officer and Chief of Provider, Family, & Safety Net Programs at MassHealth) to integrate and align LTSS clinical policy and programs with overall MassHealth strategy.
• Provide clinical leadership and mentoring for the OCA and MassHealth staff and work collaboratively with both clinical and non-clinical team members.

 

Medical Management
Contribute to MassHealth utilization management (UM) strategy/policy development and functions.

 

• Support and participate in all OCA medical management functions performed on behalf of MassHealth, including but not limited to coverage, medical necessity guidelines, utilization management and program integrity.
• Assist the Director of OCA or designee, and the Chief of MassHealth OLTSS by providing clinical input and leadership to improve UM related to MassHealth LTSS programs, including Dual Integrated Care Programs One Care, SCO, and PACE.
• Participate in communications with MassHealth medical providers, conduct peer-to-peer discussions, as applicable, and educate physicians and others on current policy and prior authorization issues.
• Participates in clinical case reviews for quality, program integrity, and fraud, waste & abuse, including but not limited to critical incident reviews and provider review committees.
• Participate and support OCA in medical management activities, including but not limited to Prior Authorization (PA), Chronic Disease Rehabilitation Hospital (CDRH) utilization management, Disability Eligibility determination (DES) audits, and Program Integrity activities.

Professional Duties and Leadership
Conducts themselves in a way that embodies medical professionalism exemplifying altruism, integrity, competency, empathy, respect for all individuals, accountability, and overall competency that appropriately promotes member and societal interests above self-interests.

 

• Provide clinical leadership and mentoring for the OCA and MassHealth staff and work collaboratively with all team members.
• Support and participate in our professional educational duty, including visiting students and trainees.
• Contribute to hiring, advising, and evaluating the performance of other staff as needed.
• Provide functional/indirect supervision of specific project/program staff as needed.

 

Qualifications:
REQUIRED EDUCATION
Medical Doctor or Doctor of Osteopathy.

REQUIRED WORK EXPERIENCE
Actively licensed to practice medicine without restriction in Massachusetts throughout his/her employment with OCA.
Board certified in internal medicine, geriatrics, family medicine or complex pediatrics with a minimum 3 years of experience in direct patient care or other relevant experience.
Excellent oral and written communication and presentation skills, including proficiency with Microsoft Word and PowerPoint.
Must work 1 day onsite during normal business hours (this position is currently Hybrid).
Proven ability to develop and successfully implement strategic initiatives and change entrenched clinical workflows.

PREFERRED EDUCATION

Graduate degree in Public Health, Public Policy, or other advanced degree in business or healthcare related area is desirable.

PREFERRED WORK EXPERIENCE
Expertise in providing direct care to complex populations (e.g., populations with medical complexity, mental illness, frailty, serious illness, disability, social risk, etc.) requiring behavioral health and/or long-term services and supports that support them.
Experience working with managed care organizations (e.g. ACO, PACE, SCO, Medicare Advantage, or Integrated Care Organizations) or health plans.
Experience in the application of state and federal Medicaid rules and regulations.
Experience with quality and performance improvement/management.
Experience with care delivery in community health centers including Federally Qualified Health Centers.

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