Vice President Senior Medical Director
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements
VICE PRESIDENT SENIOR MEDICAL DIRECTOR
The Vice President Senior Medical Director will provide leadership, direction and functional expertise on complex projects and initiatives for the Company Medical Team. Strategic oversight of cases and providing medical expertise to the Claims Division will also be required. The Vice President Senior Medical Director will coordinate and advance collaborative partnerships with other divisions as well, such as Human Resources and Underwriting, by applying medical knowledge to support the business needs.
JOB SPECIFICATIONS AND CORE COMPETENCIES
The Vice President Senior Medical Director will lead a team of medical directors and clinical analysts, driving clinical outcomes and oversight of Care/Disease Management and Population Health programs:
Leads in development of Clinical protocols, risk-stratification, and policies based on evidence-based medicine and best practices.
Assists in development and review of patient materials and education activities related to CM/DM programs.
Responsible for developing an efficient and effective Prior Authorization list for each line of business
Directs others and participates in providing clinical expertise for utilization management, care/disease management and care coordination programs. In collaboration with leadership of Care Management:
Ensures that utilization decisions are based upon medical necessity, benefit plan, and utilization of approved care guidelines and protocols.
Works with medical directors and other leaders to meet organizational goals.
Reviews, updates, and creates clinical policies as needed to ensure Care Management compliance with applicable standards and regulations.
Reviews and analyzes data and makes recommendations to the Care Management Leadership on ways to appropriately reduce medical expenses.
Responds to regulatory requests, legal reviews, complaints, and appeals regarding UM issues as necessary.
Provides clinical oversight of accreditation functions for UM and care management (CM)
Develops and reviews department policies and procedures to ensure compliance with regulatory and accrediting entities.
Develops and participates in peer review programs for providers that ensures the delivery of quality of care.
Leads in developing effective and efficient prior authorization lists for each line of business
Provides clinical support as needed for delegated entity and accreditation activities.
Provides leadership by actively participating in meetings and committee work.
Provides direct peer-to-peer discussions with Network Providers regarding specific cases as well as general protocols. Provides training and oversight to other medical directors providing similar peer-to-peer discussions.
Assists Network and Provider Operations developing programs for physicians, other providers, and members to provide orientation to the health plan, health education, provider education and feedback. Assists with provider contracting issues when appropriate.
Works with provider relations to support value based contracting partners
Works with delegated clinical entities and provides oversight and advice
Develops annual departmental budget and monitors expenditures to meet administrative cost targets.
Recruitment, management, and retention of Associate Medical Directors, Department Directors and Managers, and overall department staff.
Actively contributes to achievement of departmental goals, as identified in Department¿s annual business plan, including specific departmental process improvement plans.
Demonstrates Harris Health and Community Health Choice values, including trust, integrity, mutual respect, diversity, responsiveness and caring service.
Education/Specialized Training/Licensure: MD or DO Degree and Licensure in the State of Texas. Completion of Residency and Board Certification with preference for the Primary Care Speciales required. Masters Degree in Public Health, Business Administration or Medical Administration preferred.
Work Experience (Years and Area): Three years clinical experience with one year of administrative experience in management of a private or group practice, facility, or other similar administrative experience such as physician reviewer or medical director in a facility or health plan.
Management Experience (Years and Area): 5 years of administrative experience in Health plan management, including management of other physicians and/or clinical staff.
Software Proficiencies: Microsoft Office (Word, Excel, Outlook and PowerPoint).
Other: Experience in MLTSS is required. Must have Medicaid, Medicare and Marketplace experience.