Fallon Health Sr. Medical Director - Growing Medicaid/Medicare Health Org - Hybrid/Remote Work Model in Worcester, Massachusetts
About Fallon Health:
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
The Senior Medical Director will work closely with other physician management staff in clinical integration activities with providers and provide clinical support for all Care Services functions, including Pharmacy Programs, Quality & Health Services activities, Network Management support and development of population health management programs. This physician executive will be looked upon to assist the Chief Medical Officer in collaborative development of the medical management model and new care management initiatives for the Health Plan. This individual will also work closely with the reporting and analytics department and represent the clinical team in clinical vendor relationships. Further, this individual will provide leadership and clinical mentoring for the care management professionals and must be skilled at working collaboratively with both clinical and non-clinical staff.
Provide input for all quality management and quality improvement programs (e.g., NCQA and CMS Stars) including policies, procedures, protocols, and systems to support and promote the consistent delivery of high-quality medical care and optimization of member health.
Provide input for health and wellness programs, case management programs, disease management programs, program quality and support, and clinical program innovation.
In collaboration with the Directors of Quality and Population Management support the Health Plan’s Quality and Chronic Condition Management programs. Functions as the medical director champion for all HEDIS activity. Focuses on the integration of HEDIS activities.
Identify and develop business cases for initiatives to achieve clinically and cost-effective programs that improve member access, enhance customer satisfaction, lower medical costs, and maximize positive health outcomes and support the execution of these initiatives.
Provide assistance and support for provider relations, network development and provider contracting activities including strengthening of provider communications, improving clinical linkages and relationships with network providers.
Identify and prioritize the opportunities for appropriate Medicare Advantage and SCO provider groups to optimize care. The areas of focus will include inpatient and outpatient utilization, pharmacy utilization, and chronic care management among others.
Collaborate with Medical Economics to create Medicare Advantage and SCO provider group specific reporting that will support all cost of care and care management activities for those provider and employer groups. Coordinate with these groups to achieve understanding of and how to effectively use the data.
Represent Fallon Health at conferences and forums and with provider groups on a variety of topics as directed by the CMO.
Provide support as needed to Utilization and Care Management activities especially as related to the clinically integrated provider groups.
MD degree from accredited medical schoolwith license to practice medicine in MA (or licensable)..
Masters in Business Administration, Masters in Health Services Administration, or equivalent highly preferred.
Active certification by a member board of the American Board of Medical Specialties (ABMS).
Quality Improvement experience including direct involvement with NCQA, CMS Stars
Vendor management experience.
Demonstrated success and experience with Medicare Advantage, Medicaid, and SCO populations.
Ability to effectively develop and manage external relationships with providers and key stakeholders.
History of active participation in CMS and Medicaid audits.
Posted Date 3 months ago (7/14/2022 9:00 AM)
Job ID 6945
# Positions 1
Category Medical Management