Description

Under the administrative direction of the UPMC Insurance Services Division Commercial & Medicare Chief Medical Officer and the Chief Medical Officer, this senior leader will serve as a strategic, collaborative business partner and is responsible for the clinical strategy, operations, and compliance for the commercial products for UPMC Health Plan.  This position will also have strategic oversight and responsibility for utilization management of Commercial products and services.   This position will oversee the management of Commercial Products physicians, serve as the authority on medical issues and is responsible for compliance with all clinical medical policies, directives, rules, regulations and clinical performance standards of state and federal governments and all accrediting bodies for the Commercial line of business.  

This senior leader is accountable for ensuring the membership receives exceptional service and that clinical outcomes meet or exceed all standards or benchmarks.  He/she assures best standards of practice and promotes person centered, recovery-focused care models and policies working with internal and external stakeholders to represent an integrated approach to health.  This leader also promotes cost-effective practice patterns through appropriate interventions with health care providers while meeting or exceeding the expectations of internal and external customers by utilizing first-hand member and scientific data for continual improvements for products and services. He/she will be directly involved with interaction of physicians, hospitals, physician practices and related networks, directing and responding to risk management issues, monitoring and implementing programs to improve the quality of medical services provided. This key physician leader will be responsible for interaction with UPMC payer/provider clinical leadership (physicians, hospitals, physician practices and related networks) to further insure effective and efficient clinical care of the Commercial membership.

• Contribute clinical and operational expertise to Commercial & Medicare CMO and all senior management activities at the Insurance Services Division.
• Represent UPMC Health Plan at local, state and national forums as appropriate and directed in the oversight and management of Commercial clinical services.
• Oversee member, provider and clinical communication materials and documents for clinical content and program accuracy for the Commercial lines of business (FI, ASO, and ACA products).
• Develop and cultivate strong working relationships with regulatory entities.
• Participate in the strategic planning of the UPMC Insurance Services Division. Exemplify a collaborative approach to work ethic for staff to model.
• Establish and monitor the appropriate budget as assigned.
• Work closely with WorkPartners and UEG clinical and administrative leadership in development of cross segment strategies.
• Select, retain, develop, and reward a competent staff.
• Develop strategies to foster external relationships.
• Recommend annual plan along with the strategies, tactics and resources for Commercial Lines of Business necessary to achieve division goals and objectives directly related to the essential functions of the position.
• Manage the development, implementation, and provision of ongoing clinical evaluation of the Commercial lines of business as assigned.
• Provide leadership in advancing appropriate alternative payment models and other future opportunities.
• Oversee the standardization of practice patterns and the achievement of desired outcomes through clinical resource management.
• Provide support of the provider relations activity of the lines of business as assigned.
• Provide strategic guidance of utilization management and medical policy programs/areas as necessary to support Commercial products.
• Provide leadership for continuous NCQA activities to maintain excellent accreditation in Commercial products as appropriate.
• Support and guide the Medical Directors in the assigned lines of business in regard to meeting and exceeding standards or benchmarks for quality care and establish benchmarks or standards as needed.

*Performs in accordance with system-wide competencies/behaviors.

Qualifications

• MD license required. 
• Master's degree in business or health related field preferred.
• Senior level manager with at least five years of experience in health care delivery systems management in a managed care environment. 
• Strong QI and Utilization background with a working knowledge of finance, management information systems, and statistical analysis.  
• Direct experience with NCQA accreditation for managed care organizations. 
• Knowledge of an experience with regulatory requirements for the delivery of health plan Commercial products. 
• Must demonstrate competency in interpersonal skills and political savvy, analytical, communication, and problem-solving skills, clinical proficiency, team and customer service orientation, the ability to deal with  ambiguity and "out  of the  box" thinking. 
• Must possess the ability to interact on an academic as well as community-based level.
• Knowledge and experience with regulatory requirements for delivery of health plan Commercial products.

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life &emdash; because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.