Medical Director - DSNP/MMP

CVS Health

About The Position

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Primary Responsibilities: • Responsible for clinical oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare-Medicaid Plan) • Develop and lead clinical strategy and objectives for the DSNP/FIDE 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 DSNP/MMP and other complex health populations to optimize risk adjustment, clinical quality, and care management. • Actively participate in meetings and communication with the State Department of Medicaid in person as needed. • 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. Make face-to-face visits with medical / physical professional associates, the local provider community, state regulatory agencies and advocacy groups for discussions for trend discussions. Attend in-person provider and member meetings as needed. • 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, National Quality Management, Utilization Management, Compliance, 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 track data to improve the delivery of population health care and to create value for members, providers, and the health plan. Understand trend and create solutions. Good with data interpretation. • Effectively communicate these finding to Senior Management and staff at all levels. • Develop and deliver conference presentations or other presentations (written or oral) that support the health plan in a professional and effective manner. • Actively participate in State Fair Hearings as needed and state calls. Understand UM and participate in UM front line work and appeals in markets as needed. • 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 team meetings and leadership meetings, at the health plan, local, state, regional, or national levels. • Facilitate Interdisciplinary Care Team rounds for DSNP/MMP members. • 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. Must be willing to cross cover for other colleagues and become mentor for other MDs as needed and be on call as needed. • 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 other plan leadership as required or assigned. • Be an active voice and participate in all internal and external committee meetings. • Actively participate in quality improvement activities internal and external to the organization with multiple stakeholders. • Help achieve or exceed all applicable HEDIS, Stars and local state performance targets and goals otherwise specified for the plan. Be present for regulatory audits in-person. • Support all Clinical Quality initiatives and peer review processes including Quality of Care and Quality of Service (grievance) issues. • Actively participate in or lead quality and/or member/provider service-focused committees. • Provide clinical leadership in preparation for program audits and/or certification processes.

Requirements

MD or DO Degree and Currently Board Certified in Internal Medicine, Family Medicine, or Geriatric Medicine. "Board Eligible" will not meet requirements. Licensed in at least one state with the ability to get licensure in Ohio, New York, New Jersey, Virginia, Michigan, Florida and others as needed. Currently Licensed in Illinois, Michigan or New Jersey PREFERRED.
Active Unrestricted Board Certification in ABMS or AOA specialty.
Five 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).
Three 3+ years of experience in the managed care industry.
Experience in leading interdisciplinary teams.
Solid understanding of and concurrence with evidence-based medicine (EBM) and managed care principles.
Ability to travel on as needed basis; planned and scheduled in advance only if needed from time to time.
Proven ability to develop relationships with network and community physicians and other providers.

Responsibilities

Responsible for clinical oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare-Medicaid Plan)
Develop and lead clinical strategy and objectives for the DSNP/FIDE 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 DSNP/MMP and other complex health populations to optimize risk adjustment, clinical quality, and care management.
Actively participate in meetings and communication with the State Department of Medicaid in person as needed.
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. Make face-to-face visits with medical / physical professional associates, the local provider community, state regulatory agencies and advocacy groups for discussions for trend discussions. Attend in-person provider and member meetings as needed.
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, National Quality Management, Utilization Management, Compliance, 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 track data to improve the delivery of population health care and to create value for members, providers, and the health plan. Understand trend and create solutions. Good with data interpretation.
Effectively communicate these finding to Senior Management and staff at all levels.
Develop and deliver conference presentations or other presentations (written or oral) that support the health plan in a professional and effective manner.
Actively participate in State Fair Hearings as needed and state calls. Understand UM and participate in UM front line work and appeals in markets as needed.
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 team meetings and leadership meetings, at the health plan, local, state, regional, or national levels.
Facilitate Interdisciplinary Care Team rounds for DSNP/MMP members.
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. Must be willing to cross cover for other colleagues and become mentor for other MDs as needed and be on call as needed.
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 other plan leadership as required or assigned.
Be an active voice and participate in all internal and external committee meetings.
Actively participate in quality improvement activities internal and external to the organization with multiple stakeholders.
Help achieve or exceed all applicable HEDIS, Stars and local state performance targets and goals otherwise specified for the plan. Be present for regulatory audits in-person.
Support all Clinical Quality initiatives and peer review processes including Quality of Care and Quality of Service (grievance) issues.
Actively participate in or lead quality and/or member/provider service-focused committees.
Provide clinical leadership in preparation for program audits and/or certification processes.

Benefits

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

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