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VP, Executive Medical Director (GHP Clinical Services)

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Job Details
Job Order Number
JC141613448
Company Name
Highmark Health
Physical Address

Wilmington, DE 19806
Job Description

Company :

Gateway Health Plan

Job Description :

JOB SUMMARY

This job is accountable for the strategic direction, implementation and effective execution of physician-led functions within Clinical Services including, but not limited to, Utilization Review, Medical Policy, Member and Provider Appeals and Retrospective Review. In addition this leader will have oversight of all Medical Director activities within Clinical Services especially those related to utilization management decision making with the intent of ensuring the delivery of high quality, cost effective, evidence-based care to the Organization’s members across all products and markets.

ESSENTIAL RESPONSIBILITIES

+ Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.

+ Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.

+ Responsible for ensuring that all physician utilization management decision making is compliant with all applicable CMS and state-specific regulations and accreditation standards and that all appeals and retrospective reviews are handled consistent with applicable regulations and standards.

+ Responsible for setting the strategic direction around the development and maintenance of medical policies that are consistent with evidence-based medicine and fully compliant with all applicable CMS and state-specific regulations and accreditation standards.

+ Collaborate with Government and Regulatory Compliance to develop and update business processes as necessary to ensure full compliance with all applicable federal and state regulations.

+ Collaborate across Clinical Services and the Organization to assess market specific care cost data to identify and implement changes to product design, provider reimbursement, medical policy, prior authorization requirements and other business processes to continuously drive toward improved care cost management, reductions in practice variation and high quality patient outcomes.

+ Partner with the CMO to act as a physician advisor for sales and client managers, legislative priorities, provider relations, media relations, FIPR, product, legal, Actuary and other key business units.

+ Participate in the identification of vendors who can effectively assist the Organization in managing care costs while also ensuring a seamless member experience.

+ Other duties as assigned or requested.

EDUCATION

Required

+ Doctorate Degree – Medicine

Substitutions

+ MD or DO

Preferred

+ Master’s Degree

EXPERIENCE

Required

+ 7 – 10 years’ of prior medical/clinical staff leadership experience in one or more of the following: care management, utilization management, quality or medical policy.

Preferred

+ 3 years’ experience in all aspects of medical cost management, care management, quality and medical policy.

+ Experience in health promotion and Patient Centered Medical Homes

LICENSES or CERTIFICATIONS

Required

+ Board Certified Physician with a Current, Unrestricted PA Medical License.

Preferred

+ 3 years’ experience in all aspects of medical cost management, care management, quality and medical policy.

+ Experience in health promotion and Patient Centered Medical Homes

SKILLS

+ Excellent communication and public speaking skills, well-developed interpersonal skills and the ability to interact effectively with members, practitioners/providers, colleagues and local, State and Federal agencies.

+ Proven ability to manage a project in order to accomplish previously agreed upon desired goals within a reasonable time period

Travel Required

0% – 25%

PHYSICAL, MENTAL AND WORKING CONDITIONS

Position Type

Office Based

Teaches/Trains others regularly

Frequently

Travels regularly from the office to various work sites or from site-to-site

Occasionally

Works primarily out-of-the office selling products/services (Sales employees)

Does Not Apply

Physical Work Site Required

Yes

Lifting: up to 10 pounds

Occasionally

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Never

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.


Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

EEO is The Law

Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity ( http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf )

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

Req ID: J145489


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