Job Description

Purpose: Reporting to the CMO of Government Products, the AVP, Medicare Medical Services serves as one of the strategic and tactical leaders who works with providers and stakeholders to develop and execute on our population health strategy, clinical and provider operations, and State contract and CMS requirements for the Government products, with a focus on Medicare, including Special Needs Products for UPMC Health Plans. The AVP works closely with the President of Medicare product and Population Health functional business units to improve plan performance with the goal to realize the Quadruple Aim of better health, better care, lower costs, and higher clinician satisfaction. The role is primarily working with health plan Medicare (including Special Needs Plans) products business teams, Population Health teams, delivery system, and community leaders. This leader also promotes affordability and cost-effective practice patterns through appropriate interventions with healthcare providers and health plan programs. She/he will be directly involved in interactions with physicians, hospitals, provider practices and related networks, directing and responding to performance management, and monitoring and implementing programs to improve the quality and affordability of medical services. Responsibilities: + Co-lead performance improvement efforts for management of Medicare SNP (and related product) to include leading, educating and mentoring the clinical team and providing product specific guidance to Quality, Utilization and Care Management, and Population Health. + Participate in the creation of opportunities to consult, interact, and elicit feedback with the physician and provider community. + Develop strategies enhancing proactive clinical interventions and serving in the design and implementation of medical management initiatives to improve quality and cost effectiveness of care delivered. + Key member of the Government products clinical leadership team offering clinical insights to population health performance (quality, utilization and cost) trends, utilizing member and scientific data for continual improvements. + Collaboration with key UPMC health plan and delivery system leaders on clinical and performance improvement strategies and tactics specific to our parent health system, largest provider, and integrated delivery and financial system partner. + Provides clinical support for the Quality Improvement program, including study design for NCQA accreditation initiatives, coordination of measures reporting, as well as meeting or exceeding all regulatory requirements. + As an integral member of UPMC Health Plan's leadership team, serve as a 'role model' and 'health advocate' within the Pennsylvania community, including active participation with UPMC sponsored activities, public events and community outreach programs. + Examples of specific responsibilities include: Creating and managing performance improvement programs to improve the UPMC Network's quality and efficiency performance. + Work collaboratively with UPMC Data Analytics team to develop/improve standard performance reporting and further understand performance and opportunities for improvement. + Influence medical cost trend in partnership with network services and medical management teams including development of trend-specific initiatives and identification of medical management best practices. + Actively participates in the utilization management and quality improvement review processes, including concurrent, prospective and retrospective reviews, member grievances, provider appeals, and potential quality of care concerns. + Provide expedited review and determination of medically pressing issues in accordance with the established policies of the Health Plan. Contributes to process improvement within the Utilization Management department. + Participates in activities to support policy decision making. + Works closely with UPMC staff and others to develop informational tools and materials that support clinical quality and efficiency initiatives. o Develops strong relationships with practice group, front-line clinical, and administrative leaders supporting problem solving and improvement of quality and cost-effective practice. + Create opportunities to integrate pharmaceutical and medical strategy with innovative solutions. + Monitors network and group performance and meets regularly with key provider group Medical Directors, Administrators, and other team members to drive mutually acceptable performance goals and regularly provides feedback on the goals, including supporting practice transformation and workflow execution. + Actively interfaces with hospitals, SNFs and other care partners to improve care outcomes, utilization and cost. + An integral member of the UPMC clinical leadership team and provides support and coverage for the CMO and other Medical Directors when needed. + PA medical license required. + Minimum of 2 days per week onsite in Downtown Pittsburgh and willingness to travel throughout PA. + Master's degree in business or health related field preferred. + Direct experience with managed care organizations is preferred. + Senior level management experience with at least 5 years of experience in health care delivery systems management in a managed care environment. + Strong QI and Utilization background with a working knowledge of finance, management information systems, and statistical analysis. + Knowledge and experience with regulatory requirements for delivery of health plan products including government products and specifically Medicare and SNPs. + Competency in interpersonal skills and analytical, communication, and problem-solving skills, clinical proficiency, team and customer service orientation, and the ability to deal with ambiguity and out of the box thinking. + Must possess experience with academic and community-based providers. + Must maintain clinical specialty board certification and state licensure. May be required to add additional state licensure to support responsibilities. + Nurture personal and professional growth/development and establishing professional affiliations to keep abreast of latest trends in field of expertise. + Mentorship commitment from Chief Medical Officers and senior leaders Licensure, Certifications, and Clearances:Doctor of Medicine (MD or DO) with an active State license and Board certification UPMC is an Equal Opportunity Employer/Disability/Veteran

Job Tags

Contract work, 2 days per week,

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