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Position Summary

The Health Plan Medical Director provides leadership for the clinical care systems that improve the health of our health plan population under the guidance of the Institute for Health Improvement Triple Aim.

The Medical Director brings expertise to and executes on all aspects of the health plan’s medical policy, clinical utilization management programs and clinical benefit determinations. This role works closely with health plan leadership to ensure effective development, deployment and measurement of network activities, medical cost management initiatives, and clinical quality improvement programs to support the health of our members/patients.

Job Description

Key Outcomes:

• Participates in clinical aspects of utilization management decision-making, including the establishment of quality standards and performance audits for clinical staff to ensure consistent and accurate decisions

• Supports the selection, development and maintenance of medical policies and clinical protocols that supports utilization management, care management and chronic care management operations

• Contracts and coordinates the services of independent review organizations and individual physicians to satisfy peer reviews for utilization management and appeals decisions

• Collaborates with leadership team on the effective medical cost and utilization performance of the health plan and assists with the development and deployment of strategies for effective medical cost and quality of care management. Includes developing physician performance measurement strategies

• Partners with community providers and the medical leadership of network groups to create support for Martin’s Point utilization and population health initiatives

• Provides clinical input and guidance for Health Plan Quality Committees (e.g., credentialing, Physician Advisory Group, and delegation oversight)

• Ensures all clinical programs comply with government program regulations and NCQA accreditation requirements. This includes review of the Health Plan’s Annual Quality Management Plan.

• Provides clinical expertise to support product and benefit development efforts

• Manages the clinical aspects of member and provider appeal processing and decision-making

Education/Experience

• Medical degree with 10+ years of practice experience required, including applicable managed care experience with progressively increasing responsibilities in medical director capacities, including utilization management and medical policy development, required

• Leadership experience preferred

• Knowledge of local provider community (preferred)

Required License(s) and/or Certification(s):

• Active and unrestricted license to practice medicine in Maine or NH required

• ABMS Board Certification

Skills/Knowledge/Competencies (Behaviors):

• Extensive knowledge and practical understanding of healthcare systems and managed care concepts

• Demonstrated ability to develop medical policy and manage cost of care under the guidance of the Triple Aim

• Demonstrated ability to informally or formally lead change (internally and externally) and produce measurable results within a specified time period

• Demonstrated ability to lead, manage and collaborate with others, even without authority

• Demonstrated ability to educate and promote best practices to physician and clinical care communities

• Knowledge of and a deep commitment to performance-based health plan systems

• Good analytic skills with the ability to identify meaningful trends and targets for improvement.

• Excellent interpersonal skills and the demonstrated ability to establish rapport and working relationships with providers, service vendors, employers, regulatory and community groups.

• Strong communication and presentation skills; ability to tailor message to a variety of audiences.

• Successful utilization of process improvement tools and methods to achieve results

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org