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Looking for a chance to drive measurable and meaningful improvement in the use of evidence-based medicine, patient safety, practice variation and affordability? You can make a difference at UnitedHealthcare Community and State in serving our LTSS, DSNP, MMP and other complex population members. These complex populations will include the intellectually and developmentally disabled, substance abuse and homeless. In this role the incumbent will be part of the team changing the way health care is delivered while working with a Fortune 7 industry leader. You will be responsible for 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 MA Health Plan Chief Medical Officer.
- Oversee the implementation of a care model for a new MMP product
- Work to improve quality and promote evidence-based medicine
- Provide information on quality and efficiency to healthcare providers, patients and customers to inform care choices and drive improvement
- Support initiatives that enhance quality throughout our national network
- Ensure the right service is provided at the right time for each member
- 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
- Oversee and be responsible for clinical oversight of all LTSS, DSNP, MMP, and other non-Core Medicaid complex populations including the intellectually and developmentally disabled, substance abuse and homeless.
- Be responsible for the execution of all health care affordability, and accountable for clinical quality initiatives to achieve goals, improve HEDIS, and other quality ratings
- Work collaboratively with the Behavioral Health, pharmacy, member outreach, care management, quality and other departments to integrate social, behavioral and physical health and improve clinical program execution
- Collaborate with the local provider community, and with state regulatory agencies to improve care
- Actively participate in scheduled LTSS, DSNP, MMP, 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, , behavioral health rounds, pharmacy rounds, high risk cases, and all other interdisciplinary care team rounds for LTSS, DSNP, MMP, and other complex populations including the intellectually and developmentally disabled, substance abuse and homeless.
- Interact with the health plan's membership, provider community, health systems, nursing facilities, home and community-based networks
- Outward facing position to also interact with medical / physical professional associates, government representatives and advocacy groups to advance clinical excellence and the delivery of cost-efficient care
- Perform utilization case reviews, conduct peer to peer discussions, and appeals
- Assist in meetings with federal and state regulators
- Develop and lead clinical strategy and objectives for the One Care population, 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 LTSS, DSNP, MMP, and other complex health populations including the intellectually and developmentally disabled, substance abuse and homeless to optimize risk adjustment, clinical quality, and care management
- Collaborate with health care economics and other analytics teams required to guide and manage program direction to interpret data and extract insights that inform the health plan of 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.
- 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
- 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
- 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 triple aim
- Confer directly with providers regarding the care of patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions
- Partner with appropriate entities in the investigation of potential quality of care concerns and/or grievances
- Provide clinical leadership in preparation for program audits and/or certification processes
- Develop and deliver conference presentations or other presentations (written or oral) that support the health plan in a professional and effective manner
- 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
- Attend training sessions to acquire/enhance skills related to programs offered
- Perform other incidental and related duties as required or assigned
- 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.
- MD or DO degree
- Active, unrestricted physician Massachusetts license
- Clear of any/all sanctions by the Commonwealth of Massachusetts or Office of the Inspector General
- Not prohibited from participating in any Federally or State funded healthcare programs
- 5+ years of clinical practice experience post residency, including experience with LTSS populations, DSNP, and other complex health populations including the intellectually and developmentally disabled, substance abuse and homeless / under housed individuals
- 3+ years of medical management and general management experience, preferably in a managed care environment
- Strong understanding of and concurrence with evidence-based medicine and managed care principles
- Up to 25% travel
- You will be provisioned with appropriate Personal Protective Equipment (PPE) and are required to perform this role with patients and members on site, as this is an essential function of this role
- Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained
Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm)
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Job Keywords: Medical Director, Director, Physician Manager, Medical Management, Medical Director, DO, MD, Medical Director, Medical Management, Physician, Medicaid, Behavioral Health, United Healthcare, Community and State, LTSS, Managed Care, UHC, Healthcare, Boston, Massachusetts, MA