Senior Medical Director, Medicare & Value-Based Payment

Job Description:

Summary:

The Senior Medical Director is a strategic clinical and business leader responsible for advancing the health plan’s line of business focus through value-based care, population health, medical management, quality improvement, risk adjustment, product design, and clinical transformation. This role partners closely with line of business leadership, network and provider contracting, actuarial, finance, quality, pharmacy, analytics, care management, and operations to improve clinical outcomes, member experience, provider performance, and total cost of care while ensuring compliance with CMS requirements.

Essential Accountabilities:

• Serve a senior clinical advisor to line of business leadership on strategy, population health, medical cost, quality, and regulatory priorities, develop and execute clinical strategy in alignment with organizational growth, quality, and financial objectives.
• Identify clinical and market opportunities to improve member outcomes and competitive performance by translating clinical, utilization, quality, and financial data into actionable strategies and operating priorities.
• Establish provider performance expectations, clinical benchmarks, scorecards, and improvement strategies.
• Provide clinical leadership for medical management programs, including utilization management, prior authorization, concurrent review, case management, and care coordination by developing strategies to optimize site of care and reduce avoidable inpatient admissions, readmissions, emergency department utilization, and unnecessary high-cost services.
• Identify opportunities to improve preventive care, chronic disease management, medication adherence, member experience, and other quality measures by partnering with operational leaders to ensure medical management programs are clinically sound, member-centered, consistent, and compliant.
• Partner with Quality leadership to develop and execute quality improvement strategies monitoring performance against key quality metrics, including medical expense, PMPM trends, utilization, risk-adjusted performance, quality, and VBP results.
• Apply current knowledge of CMS, NYS and NCQA requirements, applicable federal regulations, and evolving payment and quality methodologies to support aligned business area(s).
• Performs appeals and case reviews on claims and pre-authorization requests.
• For Medicare line of business (LOB) only: Partner with Compliance, Legal, and Regulatory Affairs on Medicare-related initiatives and audits.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.