C&S Ohio MMP Medical Director
Company: UnitedHealth Group
Location: Cleveland
Posted on: June 25, 2022
Job Description:
Compassion. It's the starting point for health care providers
like you and it's what drives us every day as we put our
exceptional skills together with a real feeling of caring for
others. This is a place where your impact goes beyond providing
care one patient at a time. Because here, every day, you're also
providing leadership and contributing in ways that can affect
millions for years to come. Ready for a new path? Learn more, and
start doing your life's best work.(sm)Looking for a chance to drive
measurable and meaningful improvement in the use of evidence-based
medicine, patient safety, quality improvement science, practice
variation, and affordability? You can make a difference at
UnitedHealthcare in serving our MMP, DSNP and other complex
population members. Be part of changing the way health care is
delivered while working with a Fortune 6 industry leader.
Delivering mission driven comprehensive innovative care to improve
the health of our members and improve the care delivery system.
This position will report to the Ohio Health Plan Chief Medical
Officer.The MMP Medical Director has accountability for ensuring
that local health plan and UHC initiatives focusing on delivering
clinical excellence, quality ratings improvement with the goal to
be best in class, appropriate inpatient and outpatient
covered-service utilization and support health care
affordability.Medical Directors are expected to help drive
integrated health system transformation including working with
Accountable Care Organizations, Alternative Payment Models,
assisting to address provider network engagement and issues,
support mandated legal and contractual provisions, compliance, and
develop/lead focused improvement projects that are implemented and
successfully managed to achieve goals. The primary responsibilities
are directed towards plan activities as defined by the CMO and
collaborates with Enterprise Clinical Services (ECS) staff, Optum
Behavioral Health staff, and other market and regional matrix
partners to implement programs to support and meet market, UHC and
line-of-business goals. This position has close collaboration with
peer Medical Directors.You'll enjoy the flexibility to telecommute*
from anywhere within the U.S. as you take on some tough
challenges.Primary Responsibilities:
- Oversee and be responsible for clinical oversight of all MMP,
DSNP and other Medicaid complex populations
- Provide clinical leadership for MMP, DSNP and other Medicaid
complex populations, responsible for the execution of all health
care affordability, and accountable for clinical quality
initiatives to achieve goals, improve HEDIS, and other quality
ratings
- Develop and lead clinical strategy and objectives for MMP, DSNP
and other complex health populations, including the development and
implementation of clinical initiatives and programs to address the
needs of the populations managed to improve health outcomes
- Leverage extensive knowledge of health care delivery system,
utilization management, reimbursement methods and treatment
protocols for MMP, DSNP and other complex health populations to
optimize risk adjustment, clinical quality, and care
management
- Work to improve quality and promote evidence-based medicine and
ensure the right service is provided at the right time for each
member
- Actively participate in meetings and communication with the
Ohio Department of Medicaid
- Outward facing position to interact and collaborate with
medical / physical professional associates, the local provider
community, state regulatory agencies and advocacy groups to advance
clinical excellence and the delivery of cost-efficient care. - Will
also Interact with the members, health systems, nursing facilities,
as well as home and community-based networks
- Develop and guide the implementation of medical management
programs to ensure providers deliver appropriate, high-quality,
cost-effective health risk assessments and other clinical services
that are evidence-based
- Work collaboratively with the Behavioral Health, pharmacy,
member outreach, care management, population health, quality, and
other departments to integrate social, behavioral, and physical
health and improve clinical program execution
- In collaboration with health care analytics teams, develop
analytical models, interpret results, and extract insights on the
clinical drivers and trends and tracks data to improve the delivery
of population health care to create value for members, providers,
and the health plan
- Be able to effectively communicate these finding to Senior
Management and staff at all levels
- Provide information on quality and efficiency to healthcare
providers, patients, and customers to inform care choices and drive
improvement
- Develop and deliver conference presentations or other
presentations (written or oral) that support the health plan in a
professional and effective manner
- Support initiatives that enhance quality throughout our
national network
- Perform utilization case reviews, conduct peer to peer
discussions, and appeals
- Actively participate in State Fair Hearings
- Confer directly with providers regarding the care of patients
with severe, complex, and/or treatment resistant illnesses through
peer review and educational interventions
- Work with medical director teams focusing on inpatient care
management, clinical coverage review, member appeals clinical
review, medical claim review, and provider appeals clinical
review
- Actively participate in scheduled MMP, DSNP and other complex
population team meetings and leadership meetings, at the health
plan, local, state, regional, or national levels
- Facilitate clinical continuum rounds, case/care management
rounds, complex case rounds, Hot-spotting rounds, behavioral health
rounds, pharmacy rounds, high risk cases, and all other
interdisciplinary care team rounds for MMP, DSNP and other complex
populations
- Develop effective working relationships with internal clinical
team, facilitate educational and coaching opportunities for the
internal clinical team, as well as establish relationships and/or
consult with external agencies in pursuit of the IHI Triple
Aim
- Partner with appropriate entities in the investigation of
potential quality of care concerns and/or grievances
- Actively support compliance functions to maintain standardized
systems, policies, programs, procedures, and workflows that ensure
the health plan exceeds care management, regulatory, and quality
standards
- Support the activities of the Chief Medical Officer and other
plan leadership as required or assigned
- Be an active voice and participate in the Utilization
Management committee and the Quality Assessment and Performance
Improvement (QAPI) Committee
- Participate in quality improvement activities internal and
external to the organization with multiple stakeholders
- Contribute to the HEDIS and STARs process and improvement and
performance strategy, CAHPS and NPS improvement strategies and
support necessary Health Plan accreditation activities
- Help achieve or exceed all applicable HEDIS, Stars and local
state performance targets and goals otherwise specified for the
local Ohio plan
- Act as an improvement catalyst for all service and
quality-related efforts, influence, participate and communicate to
ACOs and other network providers or vendors on new focus and
measure/process changes
- Support all Clinical Quality initiatives and peer review
processes including Quality of Care and Quality of Service
(grievance) issues
- Responsible for representing the local Ohio plan at State-level
Fair Hearings and performing plan-level member/provider grievance
and appeals reviews, as necessary
- Actively participate in or lead Physician Advisory Committees
(PAC); Healthcare Quality Utilization Management (HQUM), Quality
Management Committee (QMC) and other associated quality and/or
member/provider service-focused committees
- The Plan Medical Director has contributing oversight
responsibility of the Ohio C&S market peer review process as
defined by State of Ohio regulator
- The Medical director will be engaged as a clinical lead for
healthcare affordability initiatives at the local market and
establishing a process for sharing data and completing peer to peer
communications as required
- Accountable for building and leaning into relationships with
internal and external partners to meet or exceed market, regional
and national requirements
- Provide clinical leadership in preparation for program audits
and/or certification processesAdditional Job Responsibilities:
- Participate in staff meetings, conference calls, and other
meetings in-person or virtually, as required or assigned
- Complete reports in a timely manner as requested by health plan
or other leadership
- Assist/coach/coordinate with other team members
- Monitor and assist in meeting regulatory requirements
- Attend training sessions to acquire/enhance skills related to
programs offered
- Perform other incidental and related duties as required or
assigned
- Must be able to effectively work in a fast-paced environment
independently and collaboratively and adhere to strict deadlines
with a quick turn-around-time -You'll be rewarded and recognized
for your performance in an environment that will challenge you and
give you clear direction on what it takes to succeed in your role
as well as provide development for other roles you may be
interested in.Required Qualifications:
- MD or DO degree
- Current and active, unencumbered, and unrestricted physician
license through the Ohio State Medical Board
- Active/unrestricted Board Certification in ABMS or AOA
specialty
- 5+ years of clinical practice experience post residency,
including experience with complex health populations and services
(must have at least three years of training in a medical
specialty)
- 3+ years of medical management and general management
experience, preferably in a managed care environment
- Solid understanding of and concurrence with evidence-based
medicine (EBM) and managed care principles
- Substantial experience in working with underserved and rural
patient populations
- Must be clear of any/all sanctions by State of Ohio or Office
of the Inspector General
- Must not be prohibited from participating in any Federally or
State funded healthcare programs -
- Domiciled in the State of Ohio -
- Full COVID-19 vaccination is an essential job function of this
role. Candidates located in states that mandate COVID-19 booster
doses must also comply with those state requirements. UnitedHealth
Group will adhere to all federal, state and local regulations as
well as all client requirements and will obtain necessary proof of
vaccination, and boosters when applicable, prior to employment to
ensure compliance. Candidates must be able to perform all essential
job functions with or without reasonable accommodationPreferred
Qualifications:
- Certification as a Certified Professional in Health Care
Quality by the National Association for Healthcare Quality (NAHQ),
Certified QI Associate by the American Society for Quality, and/or
Certified in Health Care Quality and Management (CHCQM) by the
American Board of Quality Assurance and Utilization Review
Physicians - -
- Hands-on utilization and/or quality management experience with
experience in the activities of utilization management, in
accordance with 42 CFR 438.210
- Project management or active project participation
experience
- Substantial experience in using electronic clinical
systems
- Solid data analysis and interpretation skills; ability to focus
on key metrics
- Demonstrated team-player and team-building skills
- Proven strategic thinking with proven ability to communicate a
vision and drive results
- Solid negotiation and conflict management skills
- Demonstrated creative problem-solving skills
- Hands-on experience and mastery of Quality Improvement
principles
- Experience in quality management and quality improvement as
specified in 42 CFR 438.206 through 438.370Experience:
- Clinical experience pertinent to the complex patient
population(s) being managed
- Complex care management experience
- Experience in managed care and value-based programs
- Solid experience in end-of-life issues
- Experience with cost-benefit analysis, medical decision
analysis, quality assurance and continuous quality improvement
processes
- Solid knowledge of health insurance industry trends,
reimbursement methods, and evolving accountable care and payment
models
- Passionate about new/innovative and specialized models of care
within the delivery system
- Well-versed in with extensive experience with key-driver
diagrams, flowcharts, check sheets, Pareto diagrams, cause and
effect diagrams, histograms, scatter diagrams, run and control
charts
- Well-versed in value-based contracting modelsEssential
Skills/Experience:
- Solid critical thinking and problem-solving skills
- Ability and desire to lead and continuously improve and evolve
programs
- Solid verbal and written communication skills, including
ability to present and speak in public forums
- Collaborative spirit - internal and external to the
organization
- Flexibility in daily work schedule and task assignment
- Managed care experience
- Proven ability to prioritize and multi-task
- Advanced skills in MS Office
- Ability to support and contribute to a team that values
patients, organizational and Ohio Plan success over personal
success
- Provide ongoing coaching and feedback with colleagues and other
team members to ensure peak performance
- Focus staff on the company's mission and values
- Demonstrate pro-active, solution-oriented approaches to work
efforts and drive disciplined, fact-based decisions
- Ability to focus energy on serving the patient
- Execute with discipline and urgency
- Medical Directors are viewed as a leadership position within
the health plan, experience in leading inter-disciplinary teams
preferred
- Drive change and innovation though continually seeking and
implementing novel solutions
- Demonstrated ability to create a culture that thrives on
continuous change
- Ability to inspire people to stretch beyond their comfort
zone
- Experience in challenging "the way it has always been
done"
- Model and demand integrity and compliance with all company
policies, and local, state, and federal regulations
- Proven ability to execute and drive improvements against stated
goals
- Ability to develop relationships with network and community
physicians and other providers
- Ability to successfully function in a matrix organization
exhibiting the culture of United Health Group
- Maintain a patient-focus Essential Characteristics:
- Solid leadership skills to drive performance
- Self-directed and organized
- Discrete/ability to maintain confidentiality
- Team player
- Solid attention to detail
- Sense of urgency and accountability
- Ability to articulate policy and procedure to external
stakeholders
- Ability to manage deadlines
- Ability to work under pressure
- Ability to work well independently
- Ability to take direction
- Ability to lead and influence Health Plan employees by
fostering teamwork and collaboration, driving employee engagement,
and leveraging diversity and inclusion
- Communicate and present effectively, listen actively and
attentively to others, and convey genuine interest
- Drive sound and disciplined decisions that drive action while
effectively using financial knowledge and data to manage the
business
- Drive high-quality execution and operational excellence by
communicating clear directions and expectations
- Manage execution by delegating work to maximize productivity,
exceed goals and improve performance
- Ability to travel on as needed basisTo protect the health and
safety of our workforce, patients and communities we serve,
UnitedHealth Group and its affiliate companies require all
employees to disclose COVID-19 vaccination status prior to
beginning employment. In addition, some roles and locations require
full COVID-19 vaccination, including boosters, as an essential job
function. UnitedHealth Group adheres to all federal, state and
local COVID-19 vaccination regulations as well as all client
COVID-19 vaccination requirements and will obtain the necessary
information from candidates prior to employment to ensure
compliance. Candidates must be able to perform all essential job
functions with or without reasonable accommodation. Failure to meet
the vaccination requirement may result in rescission of an
employment offer or termination of employmentGrowth, Equity,
Inclusion and Diversity The Medical Director will help deliver our
clinical value proposition focused on quality, affordability, and
service, in support of growth activities of the Ohio C&S Health
Plan, consistent with our prevailing values and culture. The plan
Medical Director reviews and edits policies, SOPs, communications
materials as required and represents the voice of the market-based
customer in program design.The Medical Director contributes to any
RFP/re-procurement activity in the state of Ohio or elsewhere, as
requested, delivering subject matter expertise and clinical
perspectives. The Ohio Plan Medical Director actively promotes
positive relations with State/local regulatory authorities and
Medical Societies, where possible, and will participate with
partner organizations. - Relationship Equity and State
ComplianceThe Plan Medical Director maintains a solid working
knowledge of all government mandates and provisions for the local
Ohio market, as well as working across the enterprise to implement
and maintain compliant clinical programs and procedures. The
Medical Director must participate as a subject-matter expert (SME)
in reviewing work plans and in operational reviews and audits. The
Medical director must be effective and positively engaged with our
external constituents such as consumers/members, physicians,
medical and specialty societies, hospitals and hospital
associations, federal/state regulators, and market-based
collaborative. The Medical Director will work collaboratively in
these activities with ongoing ECS and C&S initiatives under the
direction of the Ohio Plan CMO. The Plan Medical Director will be
called upon to support outward facing relationships to State
regulators based upon Contract, and direction of Ohio Plan CMO,
Ohio Plan President and C&S CMO and should provide clinical
thought leadership with external entities and the state. All public
speaking and media documents must be approved via appropriate UHC
protocols. All outside committee, teaching, board, or non-profit
board participation must be approved via appropriate UHC proto
Keywords: UnitedHealth Group, Cleveland , C&S Ohio MMP Medical Director, Executive , Cleveland, Ohio
Didn't find what you're looking for? Search again!
Loading more jobs...