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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

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