Med Dir., Prov Perf & Clin Transf

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

3d•$211,000 - $293,475

About The Position

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. This Medical Director role is responsible for designing, developing, and delivering provider education and performance management initiatives to support the Quadruple Aim: improve the patient and provider experience, improve population health, and improve affordability. The Medical Director will cultivate relationships with internal and external stakeholders and key providers to ensure the delivery of customized analytic and evidence based performance management solutions that support quality outcomes and value based care goals. The position will refine and devise strategy for provider and partner engagement to increase collaboration, improve care management, and encourage care delivery innovation. The Medical Director will lead a team of clinical transformation and quality improvement specialists.

Requirements

Requires an Medical Doctor (MD) or Doctor of Osteopathy (DO) degree.
Requires a minimum of 10 years clinical experience in patient centric/value based setting, NCQA certification preferred.
Requires a minimum of 5 years of medical management experience in a managed care setting.
Requires physician leadership experience in integrated delivery systems with financial accountability.
Requires experience with management of physicians and non-physicians.
Current unrestricted Medical Doctor (MD) or Doctor of Osteopathy (DO) license from the state of New Jersey
Principles of population health and value based care.
Principles of Utilization Management, URAC, NCQA UM Standards, and peer review.
State and federal regulations i.e. DOBI, DMAHS, CMS.
Principles and concepts of managed care and various models of health care delivery systems.
Principles and concepts of managed care operations, policies, and reimbursement.
Business of medical practice management.
Broad clinical knowledge and understanding of current health care issues
Strong clinical acumen to support understanding broad physical health issues, behavioral health issues, and social determinants of health.
Medical literature analysis.
Interpretation and application of medical policy to provide guidance to others.
Excellent verbal, written, and presentation skills.
Expertise in the delivery of highly technical information to a general audience.
Personal computer, applicable software.
Virtual communication platforms.
Balance clinical issues with business imperatives and directives in the context of social responsibility.
Evaluate data from various sources to identify trends and issues.
Demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
Manage multiple priorities, deliver timely and accurate work products with a customer service focus.
Ability to exercise sound judgment with strong problem solving skills.
Manage physicians and employee staff.
Build alliances with provider community and have insight into the mindset of practicing physicians in NJ.
Foster internal cross organizational collaborations to support project design and delivery.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Responsibilities

Design curriculum for provider education including but not limited to value based clinical workflows, utilization reduction strategies, quality, member experience, health equity and disparities, and appropriate risk adjustment/ coding.
Develop provider education materials and approaches for providers at varying levels of readiness to transform:
Collaborate with internal and external SMEs (e.g. other medical Directors, quality and risk adjustment teams, and others) to receive relevant materials, insights, and strategies to be incorporated
Partner with SIG and their many work-streams to ensure learnings and strategy are incorporated
Research and incorporate global, national, and state based leading evidence based practices
Use output of Voice of Provider surveys and Population health surveys to inform this work
Create provider transformation evaluation process for benchmark and interval evaluation.
Identify and refine key KPIs, in collaboration with enterprise partners, to incorporate into partner facing initiatives that will drive change in our VBP and FFS partner portfolio.
Research forward-thinking transformation practice models and programs for incorporation into partner playbooks to improve performance.
Partner with network facilities and providers to develop and implement initiatives that drive quality, manage cost and improve performance
Establish multidisciplinary teams for partner transformation engagement, for example, with transformation coach interactions, clinical collaboration calls, special KPI projects, etc.
Serve as physician SME for projects related to transformation and Health Care Value across the enterprise, such as Clinical Performance Measurement & Predictive Analytics, Strategic Initiatives Group, Medical Economics and Risk Adjustment, etc.
Design, update, implement, and review biannual value-based partner population health surveys.
Train value-based team on the interpretation of clinical insights reports and the message delivery to partners.
Research, design, update, and implement value based quality program for each program year.