Medical Director, Medical Cost Containment
The Medical Director for Commercial Products is a physician with the skills and capabilities needed to develop and execute medical cost management programs, provide clinical leadership for engagement with risk-sharing groups, work with providers on collaborative initiatives, lead clinical initiatives to promote health and well-being of the membership, provide supervision and review to medical management functions, respond to state and federal regulatory needs as directed by the CMO, support the quality initiatives of the division, represent the CMO in key internal and external meetings when deemed appropriate, work with Fraud, Prevention, and Recovery Unit on cases of potential overuse and fraud, participate in responses for escalated member or provider issues at the level requested by the CMO.
KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS
* Medical Cost Containment:
The Medical Director for Commercial Products is responsible for working with the CMO of Commercial Products to assess medical trends, develop initiatives to control overutilization and other causes of increased medical cost, and execute on initiatives through the implementation phase. The role requires a foundation of understanding of medical cost drivers and demands responsibility and accountability for initiatives.
* Provider Engagement and Collaboration:
Under the guidance of the CMO of Commercial Products, the Medical Director will work with provider groups to control their medical costs and to develop clinical programs that promote the health and well being of the THP membership. This work will require close collaboration with the contracting department in both analysis of group results and in presentations that will influence behavior. As collaborations and alternative payment models are developed, this individual will participate in clinical initiatives that support these efforts. As THP contemplates expansion into other states, the medical director will be involved in the planning and execution of the new clinical programs, responses to the new regulatory environment, and outreach to the new provider and employer groups.
* Medical Management:
The Medical Director for Commercial Products will review medical management initiatives proposed by the Enterprise and make recommendations to the CMO of Commercial Products regarding best approaches. This will include utilization management and payment policy. In addition, this individual will propose new areas for medical management and work with the CMO and with Enterprise resources to assess these opportunities.
* Clinical Programs:
The Medical Director will assist the CMO of Commercial Products in the development of clinical programs that meet the needs of the Commercial population. These programs encompass care management, disease management, and wellness programs. The medical director will be expected to independently investigate ideas for programs and work with internal resources to develop and implement the project.
* Employer and Broker Supports:
This role also will support the CMO of Commercial Products in activities with Sales and Marketing, including clinical liaison to high visibility employer groups and presentations to brokers, potential clients, or current employer groups.
The Medical Director for Commercial Products will support the quality initiatives of the Commercial division, encompassing formal metrics such as NCQA initiatives while also developing specific performance criteria for risk-sharing provider groups. In addition, the role will include responding to quality requirements in the performance guarantees to employer groups and finding unique opportunities to improve the health and well-being of the membership.
The individual will perform clinical review of coverage requests for inpatient and outpatient services and for member and provider appeals, including participating in clinical rounds, credentialing reviews, and other tasks when assigned. Review of escalated cases involving potential payment disputes, possible upcoding or potential fraud will be intermittent assignments. In discussion with the CMO of Commercial Products, other tasks may be assigned and the role may be adapted based on the changing needs of the Commercial division.
EDUCATION: (Minimum education & certifications required)
The Medical Director will be a board-certified physician with a minimum of five years of clinical experience. S/he is required to have an active and unrestricted Medical License to practice medicine in the US with licensure in Massachusetts strongly preferred.
EXPERIENCE: (Years of experience)
S/he will have a minimum of five years of clinical experience. The role also requires a minimum of five years of experience in leadership roles at health plans or provider groups. Experience working in collaborative relationships with other clinicians is required. The ability to assess, develop, and execute on projects, such as medical cost containment initiatives, is essential.
SKILL REQUIREMENTS: (Include interpersonal skills)
The role requires strong interpersonal skills and the ability to work across cross-functional teams and to persuasively present to both internal and external stakeholders. Ownership of projects from development through implementation is critical to the position. The Medical Director will be expected to balance multiple responsibilities, set priorities, and respond to unexpected changes in plans. Although there are no direct reports, this individual will be expected to influence other leaders in the company and to find the necessary resources to achieve needed results.
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 computer skills are essential. Some travel will be expected and there will be occasional evening or early morning meetings. Most work will be performed on site but some remote work is acceptable.
CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, 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.