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   Current UPMC employees must apply in HR Direct

VP, Medical Management

  • Job ID: 210002RP
  • Status: Full-Time
  • Regular/Temporary: Executive
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: Medical Director Service
  • Location: 600 Grant St, Pittsburgh PA 15219
  • Union Position: non union
  • Salary Range: $0 / hour

Description

Purpose:

Under the administrative direction of the UPMC Insurance Services Division 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 medical management areas of UPMC Health Plan, including utilization management (UM) and medical policy. This position will also have strategic oversight and responsibility for utilization management of all products and services, working closely with senior clinical line of business leadership. This position will oversee the management of Utilization management and medical policy senior physicians, serve as the authority on medical management 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 all lines of business, to include Commercial, Exchange, Medicare Advantage, Medicaid, CHIP and Community Health Choices. 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 in the medical management areas. 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 through medical management initiatives.

*Remote work flexibility will be considered.


Responsibilities:

  • Contribute clinical and operational expertise to 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 Medical Management clinical services.
  • Oversee member, provider and clinical communication materials and documents for clinical content and program accuracy for all products regarding UM and medical policy.
  • 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.
  • 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 Medical Management 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 medical policy and UM as assigned.
  • Work closely with Senior and Executive leadership in developing appropriate medical management strategies specific to each line of business.
  • 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 for medical management of the lines of business as assigned.
  • Provide strategic guidance of utilization management and medical policy programs/areas as necessary to support all UPMC Health Plan products.
  • Provide leadership for continuous NCQA activities to maintain excellent accreditation focusing on medical management activities and requirements.
  • Provide clinical guidance to Quality focusing on regulatory clinical guidelines and credentialing activity. This would include providing clinical support of Quality-of-Care issues and chairing the internal Quality Improvement Committee.
  • Support and guide the Medical Directors in the assigned lines of business regarding meeting and exceeding standards or benchmarks for quality care and establish benchmarks or standards as needed.
  • Provide leadership for continuous NCQA activities to maintain excellent accreditation focusing on medical management activities and requirements.
  • Provide clinical guidance to Quality focusing on regulatory clinical guidelines and credentialing activity. This would include providing clinical support of Quality-of-Care issues and chairing the internal Quality Improvement Committee.
  • Support and guide the Medical Directors in the assigned lines of business regarding meeting and exceeding standards or benchmarks for quality care and establish benchmarks or standards as needed.

Qualifications

Doctor of Medicine (MD)

Licensure, Certifications, and Clearances: 

Doctor of Medicine (MD)

 

UPMC is an Equal Opportunity Employer/Disability/Veteran

 

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   Current UPMC employees must apply in HR Direct