Job Description

Job Title: Sr Medical Director-Employee Group
Job ID: 615564
Status: Full-Time
Regular/Temporary: Management
Hours:
Shift: Day
Facility:
Department: Medical Director Service
Location: 600 Grant St, Pittsburgh PA 15219

Description

The Senior Medical Director will have the rare and exciting opportunity to join a senior team recognized as UPMC's best and brightest leaders. He/she will shape the way UPMC Health Plan manages all clinical aspects of Medical Affairs. As an integral part of the organization, it is paramount that this physician business executive exhibits leadership qualities and expertise that will raise UPMC Health Plan to new levels of excellence and execution. The success of UPMC Health Plan will rely upon this individual's creativity, discipline, detail and a passion to 'make a real difference' beyond conventional managed care. He/She will create a standard for measurable clinical excellence by which competitors will be evaluated, resulting in the acquisition of profitable, long-term market share in the region.

Responsibilities:
  • As a clinical 'thought leader' and UPMC Health Plan physician liaison, participate in the creation of opportunities to consult, interact and elicit feedback with the physician community, then act upon this valuable information, raising proactive clinical intervention to unprecedented levels.
  • As an integral member of UPMC Health Plan's leadership team, serve as a 'role model' and 'health advocate' within the Western Pennsylvania community, including active participation with UPMC sponsored activities, public events and community outreach programs.
  • Assist with the development of a clinical organization which prioritizes the retrieval and intuitive interpretation and evaluation of statistics and medical trends in order to establish aggressive preventative health targets and objectives.
  • Collaborate with VP, Medical Affairs and to engage all functional areas of the Health Plan from a clinical perspective to develop innovative programs as well as products lines; serving as the primary clinical liaison with Network Services, Strategic and Advisory Services, Finance and Underwriting, Operations, Information Systems, Pharmacy, and Product Development.
  • Collaborate with VP, Medical Affairs, and Health Plan senior leadership in the development of short-term, mid-term, and long-range strategic planning for the Health Plan. Partner with physician leaders, and hospital and business executives to exceed clinical, operating, financial, quality, and market share objectives. Deliver executive level presentations for UPMC senior management and other designated groups.
  • Collaborate with physicians to develop clinical programming by accessing and mining clinical data, devising methods to manage populations. Partner with physicians to improve reimbursement model and performance based physician incentive programs.
  • Collaborate with the VP, Medical Affairs and Chief Medical Officer to develop unique partnerships and differentiated relationships with current and prospective employer groups, consultants and brokers, in order to understand and meet their health and welfare needs.
  • Create progressive physician group and provider education programs; direct concurrent education and communication related to credentialing, UM, and QI. The Senior Medical Director will be responsible for the Technical Assessment Committee (TAC).Establish and implement superior performance standards while maintaining compliance with applicable statutes, rules and regulations, the standards of accrediting bodies and corporate policies and compliance program standards.
  • Ensure continuous improvement strategies are established and implemented for Health Management outcomes and processes, encouraging a culture which initiates intensive and persistent case management for members.
  • Identify opportunities to further integrate information systems and departmental interface capabilities, and from a clinical perspective, assist in affecting the 'phase-in' of newly acquired OAO interactive software.
  • Influence medical cost trend in partnership with network services and medical management team, including development of trend-specific initiatives, provider fee schedule review, and identification of medical management best practices. Create opportunities to integrate pharmaceutical and medical strategy with innovative solutions.
  • Interface with UPMC Health System cross-functional and shared resources to further the 'cause' to create a seamless healthcare patient-flow management process and insurance model.
  • Lead the Utilization Management organization, Pod functions, as well as Quality of Care; leading management of 2nd level grievances, guiding and managing the most complex cases, appeals, quality regulatory requirements, credentialing, trouble-shooting and special investigations.
  • Motivate and mentor UPMC Health Plan's clinical Medical Affairs staff by 'setting the pace' and fostering 'excellence by example'. Assess the overall team, including ongoing recruitment and hiring of talent. Ensure that the organization has the 'right people' in the 'right positions' and that the organization's structure is designed to maximize results.
  • Nurture personal and professional growth/development by attending seminars, workshops, and establishing professional affiliations to keep abreast of latest trends in field of expertise.
  • Passionately manage UPMC Health Plan's clinical Medical Affairs organization for Commercial, Medicare and Medicaid lines of business, to include; leading, educating and mentoring Medical Directors, managing all clinical aspects of Medical Management, Quality, Health Management, Utilization Management, Disease Management, Strategic Planning and Policy.
  • Provide clinical leadership and support for Quality Improvement program, including study design for NCQA accreditation initiatives, coordination of HEDIS reporting, as well as meeting or exceeding all regulatory requirements. Serve as Clinical Leader for the UPMC for Life Medicare program.
  • Serve as an integral part in the design and implementation of medical management initiatives such as disease management to improve quality and cost effectiveness of care delivered to Commercial, Medicare and Medicaid members.
  • Serve on physician committees and work with each Health Management program to monitor, assess and ensure the program's clinical success. Establish best practices for care programs including Diabetes, Asthma, Congestive Heart Failure, End-Stage Renal Disease and Maternity Programs.
  • Swiftly respond to challenges and/or opportunities as they arise. Develop and implement innovative programs to act on historical data, identifying new trends, retooling existing approaches, and analyzing the competition.

Qualifications

  • M. D. Degree is required
  • Masters Degree is preferred in healthcare, marketing, business administration, or other related fields of study.
  • Experience in commercial insurance industry highly preferred.
  • Extensive experience in clinically leading Medical Affairs within a progressive managed care organization, ideally having created and driven innovative clinical program initiatives as well as having initiated NCQA accreditation and certification. 
  • Experience within a health plan that has truly developed a relationship with the physician and patient community; genuinely collaborative in nature, value-added versus commodity-driven, cross-functionally efficient and consumer-driven. 
  • Possess a passion and commitment to help change the way healthcare is delivered, a track record of developing leading-edge Health Plan clinical strategies while motivating an organization to achieve stretch goals to drive innovation, and do what is right today, rather than tomorrow. 
  • Ability to lead, motivate and mentor superior Medical Directors in pursuit of progressive programming.  
  • Solicit support, evaluate, direct and hold ones self and employees accountable, while maintaining high morale and productivity during favorable and unfavorable conditions. 
  • Expert managed care clinical leadership skills, leveraging a broad knowledge base in managed care. 
  • Possess a global understanding of the industry: legislative/regulatory developments, national product and delivery trends, maintenance of key industry relationships and tracking competitors. 
  • Highly developed interpersonal and communication skills, both written and verbal, and an executive demeanor which interacts effectively with all organizational stakeholders regarding sensitive and/or complex topics. 
  • Ability to plan and schedule multiple tasks/projects and to maintain control of ones own and others work flow to achieve results ahead of schedule and within budget. 
  • Highly developed analytical skills. 
  • Operate effectively in a matrix environment. Views the various matrix partners within UPMC as customers. 
  • Possess the appropriate level of patience, and persistence, to move issues forward while competing in a highly complex, turbulent, and market-driven industry. 
  • Exude a leadership style emphasizing collaboration, teamwork, participation and communication.  
  • Willingness and ability to delegate responsibility to senior subordinates while allowing them room to identify ways and means to `take action and accomplish specific goals and objectives. 
  • Contribute imaginative and innovative ideas; encourages idea generation of others; open, accessible and communicative; sensible, fair and objective in decision-making; willing and able to confront difficult choices. 
  • Possess unquestioned integrity; trusting of others and worthy of their trust; a consensus-builder in a transforming organization; highly accomplished in interpersonal diplomacy; active and energetic, a self-starter, well organized and efficient.  

Licensure, Certifications, and Clearances:
Pennsylvania MD or DO license required

  • Doctor of Osteopathy or Medical Doctor

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Union Position: No

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