UPMC is actively seeking a full time Senior Medical Director, CHC and SNP SW, for UPMC Health Plan. This role will be Monday- Friday in the downtown Pittsburgh office, located in the US Steel Tower. This position will report to the AVP of Medical Services.
Under the general direction of the AVP of Medical Services, the Senior Medical Director-CHC & SNP SW (Southwest) will provide leadership and clinical direction for the new CHC Product, launched in January 2018. In this position, the Senior Medical Director-CHC/SNP SW will have the exciting opportunity to join a senior team of UPMC's best and brightest leaders to develop and shape the way UPMC Health Plan develops and implements the new CHC product. He/she will work in close collaboration with the SMD CHC/SNP SE for all aspects of the program affecting both the program in general and/or specific members in both the Southwest and Southeast, as well as with clinical and operational leaders at the Health Plan, community providers, local and state government officials, and consumers. He/she will demonstrate the leadership qualities, clinical expertise, creativity and discipline needed to think broadly and strategically in order to create a standard for measurable clinical excellence for all CHC members. He/she will also demonstrate the ability to use these same skills to create an integrated approach to those UPMC CHC members who are also members of UPMCHP's Special Needs Plan. He/she will create a standard for measurable clinical excellence by which competitors will be evaluated, resulting in the acquisition, maintenance and growth of profitable, long-term market share in the region.
Demonstrate the proven ability to work in collaboration with both physician and non-physician teams in direct supervisory, consultant, and/or team member roles.
Use this ability to collaborate with CHC operational and clinical teams on all clinical, quality, regulatory and other relevant matters.
In a similar fashion, in collaboration with the CHC Southwest operational and clinical teams, serve as the UPMCHP physician lead for Southwest community providers and services. In this capacity, the SMD Southwest will serve as a role model and health advocate within the Southwest PA community, including active participation in UPMC sponsored activities, public events and community outreach programs.
In collaboration and coordination with the SMD CHC/SNP SE, as well as the CMO of Medicaid, AVP Medical Services, and other UPMCHP leaders, serve as physician lead and contact with DHS, OLTL, SNP and other regulatory and quality departments in Harrisburg.
This responsibility includes attending meetings in Harrisburg as well as developing and implementing a consistent and disciplined approach to report back to others in the CHC/SNP leadership group in a comprehensive and useful manner.
In conjunction and collaboration with the SMD CHC SE, provide clinical leadership for utilization management, policy, complaints and grievances, and all regulatory matters relevant to CHC Collaborate with these subject matter experts across the organization to determine how issues and processes may be developed and potentially modified to maximize clinical applicability and process efficiencies both for LTSS services specifically and for any of those processes that affect both LTSS and SNP ( including requirements in general and those that affect particular members).
This responsibility includes serving as the primary CHC physician for all LTSS reviews and serving as the primary CHC physician for all C and G matters, including assuming primary clinical responsibility for the grievance review process for LTSS.
Nurture personal and professional growth/development by attending seminars, workshops, and establishing professional affiliations to keep abreast of latest trends in MLTSS nationwide and in clinical area of expertise.
Provide clinical leadership and support for Quality Improvement Programs (e.g. PIPs). HEDIS, NCQA accreditation, CMS Star and any other quality matters.
Serve as Clinical Leader for UPMC CHC program in the Southwest region. This primary responsibility includes but is not limited to: 1) oversight and assurance of the highest quality of clinical service for all CHC members, including the development and implementation of strategies and processes that provide the highest clinical quality for members ; 2) development of an integrated and innovative clinical approach for aligned CHC/SNP members, including working with leadership across the health plan to assess and ensure the program's clinical and financial success; 3) collaboration with CHC and SNP clinical case management and service coordinator teams on all clinically relevant service and quality matters, including participation in interdisciplinary team meetings and case reviews, 4) collaborate with HP physicians and other HP teams to develop clinical programming by accessing and mining clinical data and devising methods to manage populations and sub-populations. and 5) from a clinical perspective assist in effecting the phase-in of newly acquired IS systems and approaches and the identification of opportunities to further integrate information systems and departmental interface capabilities to improve the clinical oversight and management of the program.
Serve as the UPMCHP physician lead for CHC for the physician network in the Southwest. In collaboration with CHC, SNP, and other Health Plan departments, assume a leadership role in the creation of opportunities to consult and interact with physicians and other physical healthcare providers in the Southwest. Devise and implement a strategic approach to educate and engage the provider community in the Southwest regarding CHC. Using deep knowledge of the Southwest physician community, act in capacity of expert consultant within the Health Plan for matters involving the Southwest provider community.
Serve on physician committees and work with others across the organization to establish best practices for clinical programs, including, e.g., Diabetes, Asthma, Congestive Heart Failure, End-Stage Renal Disease and others
Under the direction of the CMO, Medicaid and Behavioral Services and the AVP of Medical Services for CHC and SNP, collaborate with all functional areas of the Health Plan (e.g., Network Services, Strategic and Advisory Services, Finance and Underwriting, Operations, Information Systems, Pharmacy, Product Development, etc.) to ensure that the product is viable and profitable, while simultaneously meeting the highest quality standards and delivering outstanding value for our members
This responsibility includes a deep understanding of the medical cost management of both aligned CHC SNP members and unaligned members and recommending approaches to improve value.
As part of this responsibility, the SMD SW will demonstrate the ability to develop and implement innovative programs which take into account historical data, the identification of new trends, recognition of when existing approaches can and need to be retooled, and the analysis of the competition when needed.
Under the general direction of the CMO of Medicaid and the AVP of Medical Services, work as a team member with the SMD CHC SE to develop clinical approaches, quality approaches and processes to meet all regulatory requirements across the state of Pennsylvania for CHC.
Doctor of Medicine or Doctor of Osteopathy five to ten years of post-residency clinical experience
Minimum of five years of managed care experience
Board Certification in ABMS Unrestricted Pennsylvania Medical License
Experience in Government programs preferred
Experience in utilization management, clinical program development, medical policies, and/or quality programs preferred
Experience and familiarity with use of data to drive strategic and tactical decision-making
Demonstrated ability to maintain effective professional relationships with all levels of executive and medical staff, including professional and institutional providers of care
Licensure, Certifications, and Clearances:
Board Certification in ABMS
Doctor of Osteopathy or Medical Doctor
Additional Salary Information: Base salary with bonus structure
Internal Number: 767536
About University of Pittsburgh Medical Center (UPMC) Health Plan
UPMC Health Plan, headquartered in Pittsburgh, Pennsylvania, is among the nation's fastest-growing health plans. It is owned by the University of Pittsburgh Medical Center (UPMC), a world-renowned health care provider. As part of an integrated health care delivery system, UPMC Health Plan is committed to providing its members better health, more financial security, and the peace of mind they deserve. UPMC Health Plan partners with UPMC and community network providers to produce a combination of knowledge and expertise that provides the highest quality care at the most affordable price. The UPMC Insurance Services Division — which includes UPMC Health Plan, WorkPartners, UPMC for Life, UPMC for You, UPMC for Kids, and Community Care Behavioral Health — offers a full range of group health insurance, Medicare, Special Needs, CHIP, Medical Assistance, behavioral health, employee assistance, and workers' compensation products and services to more than 3.4 million members. Our local provider network includes UPMC as well as community providers, totaling more than 140 hospitals and more than 23,300 physicians throughout Pennsylvania and parts of Ohio, West Virginia, and Maryland.
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