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Medical Director in Southfield, MI at Accident Fund Holdings, Inc

Date Posted: 3/21/2019

Job Snapshot

Job Description

SUMMARY: The Medical Director for Medicare quality and clinical performance is responsible for providing medical leadership in one or more medical areas or functions, including: enterprise development of the Medicare Stars program including HEDIS (clinical and pharmacy measures), HOS, and CAHPS strategy; enterprise development and execution of value capture initiatives, and; Medicare network management and provider outreach.

RESPONSIBILITIES/TASKS:

Overall

  • Provides thought leadership relative to the Medicare star program as well as to the value capture and network management teams;
  • Identifies key improvement areas and participates in result-driven program development across the business unit and vendor teams;
  • Helps develop appropriate reporting for SHS to provide oversight of clinical trend and quality management;
  • Reviews quantitative and qualitative data in developing plans to achieve goals;
  • Provides leadership, planning, project coordination and management for the development of a cost-effective department while concurrently facilitating efficient operations to meet current and future business needs within the organization;
  • Represents Senior Health Services in community and industry programs and conferences;
  • Upon request, functions as the department head in the absence of the executive leader;
  • Responsible for balancing workload to optimize the effectiveness of the department;
  • Performs other work-related duties and responsibilities as directed, assigned or requested.

Clinical Quality (Medicare STARS)

  • Is responsible for overseeing the implementation of the strategic plan to achieve and retain 4.5-star goal;
  • As a key member and clinical leader in a high-functioning team, participates in the ideation of market-leading innovations that improve the organization's Stars scores;
  • Delivers messaging across the enterprise and with key accounts relative to ongoing star performance, outlook, strategies, and impacts.

Value Capture

  • Identifies and tracks key areas of improvement opportunity for ingestion into the value capture pipeline, care management operational improvements;
  • As a key member and clinical leader in a high-functioning team, participates in the ideation of market-leading innovations that improve the organizations Stars scores;
  • Delivers analytic insights related to cost and use, advising leadership and the team of emerging negative trends and inappropriate utilization (under and/or over), and participates in the ideation of initiatives aimed at improving the overall cost of care for Senior Health Services members.

Network Management

  • Provides clinical input/guidance into regional network development and contracting issues (including network policies and procedures) and participates in provider contract negotiations as needed;
  • Strengthens provider relationships and builds provider support by aligning loyalties with Senior Health Services;
  • Educates providers and facilitates integration of managed care knowledge and clinical and cost-effective practice skills into network policy and actual clinical practice;
  • Communicates effectively and works closely with providers to improve member satisfaction, clinical outcomes, appropriate use of clinical resources, access, effectiveness and costs;
  • Helps implement improvements in overall network design and performance required for 4-star or greater outcomes. This includes monitoring provider network outcomes and assisting the network management team to drive star ratings, value capture and risk revenue optimization; paying attention to risk arrangements, incentives, network qualification criteria, provider relationships, and member attribution to drive sound narrow network performance;
  • Educates physicians on clinical documentation opportunities as well as performance improvement methodologies.

DIRECTION EXERCISED:

May directly supervise exempt and non-exempt staff in accordance with company policies and applicable Federal and State Laws. Responsibilities include, but are not limited to, effectively interviewing, hiring, terminating, and training employees; planning, assigning and directing work; appraising performance; rewarding and counseling employees; addressing complaints and resolving problems; and supporting and encouraging the engagement process.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.