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Medical Director

Employer
Tufts Health Plan
Location
Watertown, Massachusetts
Posted Date
May 3, 2016
Reference
16-8698

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The Director of Medical Affairs will be a physician responsible for the management and oversight of the medical affairs department including management of the physician processes in support of utilization management and transactional functions for all Tufts Health Plan products. These functions include performance of prospective, concurrent and retrospective utilization review, and non-UM transactional work including but not limited to DRG, bridging and retrospective provider claims dispute reviews. The Director for Medical Affairs will work closely with staff from Precertification/Intake/Medical Management, Care Management, Claims Operations, and the Appeals and Grievance departments on these review activities. The director is responsible for the day-to-day transactional operations of the MAD. He/she is responsible for the monitoring and oversight of the UM functions performed within the MAD and the delivery and review of defined metrics to validate business unit/program effectiveness and ensure appropriate resources are assigned to meet divisional needs. He/she is charged with ensuring compliance with requirements for all regulatory and accreditation authorities related to the department's work and is responsible for ensuring the MAD departmental processes are applied and followed by his/her direct reports and other physicians who perform UM and transactional work. The director works collaboratively with Health Care Services/Clinical Services and other appropriate Tufts HP departments across product lines to identify and address opportunities to improve service, reduce administrative cost, and support department and organizational business goals. The director is also accountable for direct supervision, evaluation, management, and ongoing development of reporting staff.

KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS

Medical Director for Utilization Management/Director of Medical Affairs Department
* Provide clinical and policy expertise for all aspects of physician UM serving as the representative for MAD on relevant projects including system implementation, service area, and product expansion
* Working together with HCS' Directors of Medical, Behavioral Health and Utilization Management, monitor UM processes to identify opportunities for improvement and efficiency
* Manage team-specific and/or departmental projects, as assigned by the department leadership
* Track and report to Manager any compliance or publicity risks including root cause analysis and any corrective actions.
* Monitor quality and production standards through the interpretation of data and metrics. Ensure interdepartmental service level agreements are met.
* Together with program manager, develop, review, revise, and monitor policies and procedures to ensure that all work of the department meets all regulatory and accrediting standards for all products.
* Ensure all regulatory, operational, and documentation standards and reporting needs are met
* Manage the day to day integration of technology to support department transactional functions
* Coordinate physician scheduling
* Establish and reinforce processes for implementing various inputs of information to support all lines of business including assessing and implementing new technology
* Continuously work to identify and implement administrative efficiencies within the department
* Responsible for the employee engagement program within the department.
* Serve as a clinical resource to both non clinical and clinical THP staff

Transactional Work
* Perform clinical review of prospective, concurrent, and retrospective coverage requests and standard and expedited appeals for inpatient and outpatient services requiring prior authorization and medical review
* Support the provider inquiry line
* Provide physician support and leadership for care management rounds and care planning activities for all products as required
* Participate in inter-rater reliability exercises
* Perform provider claims dispute reviews
* Perform DRG and bridging reviews
* Provide physician expertise for the development/modification of claims payment rules
* Participate in training for Tufts Health Plan physicians

Administrative
* Participate in or lead relevant committee and staff meetings producing appropriate documentation and carrying out follow-up as needed to ensure business objectives are met
* Serve as internal consultant/clinical resource to other departments of Tufts Health Plan as needed
* Represent Medical Affairs and VP Medical Management and Quality in relevant external meetings and initiatives as needed
* Represent Tufts Health Plan as member of the MHQP health plan council
* Represent Tufts to its external customers in area of specialty as needed

Staff Development
* Provide direct oversight of physician UM reviewers
* Guide and enhance the professional development of direct reports.
* Engage staff in the development of individual development plans and support developmental activities that are aligned with the employee's plan to achieve goals.
* Create a team succession plan that provides opportunities for growth and ensures business process continuity.
* Design and maintain a comprehensive team orientation & training program that results in successful onboarding of new UM staff and continuous education for existing staff
* Be a resource to THP and MAD staff for complex situations.

EDUCATION: (Minimum educations and certifications required)
Medical Director, will be a Board Certified MD who has had at least five years of clinical experience. S/he is required to have a current unrestricted Massachusetts license as a medical or osteopathic doctor. S/he will have medical management experience, either at another health plan or at a local provider unit, medical group, or health care facility

EXPERIENCE: (Years of experience)
Minimum five years of clinical experience. S/he will have medical management and UM experience, either at another health plan or at a local provider unit, medical group, or health care facility. A demonstrated ability to successfully manage staff, operational programs, projects or departments, lead people and work at all levels of an organization to achieve the intended results, demonstrated experience managing employees, and selecting and developing clinical leaders is required.

SKILL REQUIREMENTS: (Include interpersonal skills)
Proven ability to take ownership for initiatives, achieve goals and support "bottom line" results.
Ability to work within and lead cross-functional teams to efficiently accomplish objectives
Be an effective "team player", with excellent interpersonal, cross-departmental and leadership skills.
Influencing others -- particularly those outside of direct reporting relationships
Planning and execution - Ability to oversee assessment, development, and implementation of iniatives and monitor implementation and modify accordingly.
Coaching and Mentoring - primarily of reports, but also of others the skills to help train, educate, and mentor more junior physicians
Strong results orientation - drives to meet business goals
Ability to handle multiple demands--must be able to effectively balance multiple priorities
Performs utilization management activities in accordance with accreditation standards and regulatory guidelines described in Tufts Health Plan UM Policy and Procedure Manual and in accordance with Tufts Health Plan Medical Necessity Guidelines and the member's benefit document
Render claims payment dispute decisions following Tufts Health Plan claims payment policies
S/he will have an understanding of principles of utilization management and quality assurance.
S/he will have the skills to communicate with and educate Tufts Health Plan participating physicians in a non-confrontational manner. S/he will be an effective "team player", with excellent interpersonal, cross-departmental, and leadership skills.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)
Tufts Health Plan is a fast paced professional environment requiring a high level of initiative and robust decision-making skills. Effective use of a personal computer is important. While this position is considered as part-time, given the dynamic nature of the work environment and professional nature of the role, there may be occasions where some additional work in the course of a given week may be necessary. In addition, there may be occasional early morning or evening meetings.

CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Will be exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy and department guidelines/policies and all applicable laws and regulations at all times.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.

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