JOB SUMMARY The Vice President, Senior Medical Director will provide leadership, direction and functional expertise on complex projects and initiatives for the Company Medical Team. Strategic oversight of cases and providing medical expertise to the Claims Division will also be required. The Vice President Senior Medical Director will coordinate and advance collaborative partnerships with other divisions as well, such as Human Resources and Underwriting, by applying medical knowledge to support the business needs.
JOB SPECIFICATIONS AND CORE COMPETENCIES * The VP, Sr. Medical Director will lead a team of medical directors and clinical analysts, driving clinical outcomes and oversight of Care/Disease Management and Population Health programs: * Leads in development of Clinical protocols, risk-stratification, and policies based on evidence-based medicine and best practices. * Assists in development and review of patient materials and education activities related to CM/DM programs. * Responsible for developing an efficient and effective Prior Authorization list for each line of business. * Directs others and participates in providing clinical expertise for utilization management, care/disease management and care coordination programs.
In collaboration with leadership of Care Management: * Ensures that utilization decisions are based upon medical necessity, benefit plan, and utilization of approved care guidelines and protocols. * Works with medical directors and other leaders to meet organizational goals. * Reviews, updates, and creates clinical policies as needed to ensure Care Management compliance with applicable standards and regulations. * Reviews and analyzes data and makes recommendations to the Care Management Leadership on ways to appropriately reduce medical expenses. * Responds to regulatory requests, legal reviews, complaints, and appeals regarding UM issues as necessary. * Provides clinical oversight of accreditation functions for UM and care management (CM) * Develops and reviews department policies and procedures to ensure compliance with regulatory and accrediting entities. * Develops and participates in peer review programs for providers that ensures the delivery of quality of care. * Leads in developing effective and efficient prior authorization lists for each line of business.
* Provides clinical support as needed for delegated entity and accreditation activities. * Provides leadership by actively participating in meetings and committee work. * Provides direct peer-to-peer discussions with Network Providers regarding specific cases as well as general protocols. Provides training and oversight to other medical directors providing similar peer-to-peer discussions. * Assists Network and Provider Operations developing programs for physicians, other providers, and members to provide orientation to the health plan, health education, provider education and feedback. Assists with provider contracting issues when appropriate. * Works with provider relations to support value based contracting partners * Works with delegated clinical entities and provides oversight and advice
Department Oversight: * Develops annual departmental budget and monitors expenditures to meet administrative cost targets. * Recruitment, management, and retention of Associate Medical Directors, Department Directors and Managers, and overall department staff. * Actively contributes to achievement of departmental goals, as identified in Department?s annual business plan, including specific departmental process improvement plans. * Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service.
MINIMUM QUALIFICATIONS: Education/Specialized Training/Licensure: MD or DO Degree and Licensure in the State of Texas. Completion of Residency and Board Certification with preference for the Primary Care Specialest required. Masters Degree in Public Health, Business Administration or Medical Administration preferred. Work Experience (Years and Area): Three years clinical experience with one year of administrative experience in management of a private or group practice, facility, or other similar administrative experience such as physician reviewer or medical director in a facility or health plan. Management Experience (Years and Area): 5 years of administrative experience in Health plan management, including management of other physicians and/or clinical staff. Other: Experience in MLTSS is required. Must have Medicaid, Medicare and Marketplace experience.
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.