20 days old

Complex Care Medical Director - Iselin, NJ

Iselin, NJ 08830
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  • Job Code
LTSS/DSNP/FIDESNP/Complex Care Medical Director

Looking for a chance to drive measurable and meaningful improvement in the use of evidence-based medicine, patient safety, practice variation and affordability? You can make a difference at UnitedHealthcare in serving our LTSS, DSNP/FIDESNP, and other complex population members. Be part of changing the way health care is delivered while working with a Fortune 6 industry leader. Delivering mission driven comprehensive innovative care to improve the health of our members and improve the care delivery system. This position will report to the NJ Health Plan Chief Medical Officer.

Primary Responsibilities:
€ Work to improve quality and promote evidence-based medicine
€ Provide information on quality and efficiency to healthcare providers, patients and customers to inform care choices and drive improvement
€ Support initiatives that enhance quality throughout our national network
€ Ensure the right service is provided at the right time for each member
€ Work with medical director teams focusing on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review and provider appeals clinical review
€ Oversee and be responsible for clinical oversight of all LTSS, DSNP/FIDESNP, and other non-Core Medicaid complex populations
Provide clinical leadership for LTSS, DSNP/FIDESNP, and other non-Core Medicaid complex populations, responsible for the execution of all health care affordability, and accountable for clinical quality initiatives to achieve goals, improve HEDIS, and other quality ratings
€ Work collaboratively with the Behavioral Health, pharmacy, member outreach, care management, quality and other departments to integrate social, behavioral and physical health and improve clinical program execution
€ Collaborate with the local provider community, and with state regulatory agencies to improve care
€ Actively participate in scheduled LTSS, DSNP/FIDESNP, and other complex population team meetings and leadership meetings, at the health plan, local, state, regional, or national levels
Facilitate clinical continuum rounds, case/care management rounds, complex case rounds, Hotspotting rounds, behavioral health rounds, pharmacy rounds, high risk cases, and all other interdisciplinary care team rounds for LTSS, DSNP/FIDESNP, and other complex populations
€ Interact with the health plan's membership, provider community, health systems, nursing facilities, home and community based networks
€ Outward facing position to also interact with medical / physical professional associates, government representatives and advocacy groups to advance clinical excellence and the delivery of cost efficient care
€ Perform utilization case reviews, conduct peer to peer discussions, and appeals
€ Assist in meetings with state Medicaid department
€Develop and lead clinical strategy and objectives for LTSS, DSNP/FIDESNP and other complex health populations, including the development and implementation of clinical initiatives and programs to address the needs of the populations managed to improve health outcomes
Leverage extensive knowledge of health care delivery system, utilization management, reimbursement methods and treatment protocols for LTSS, DSNP/FIDESNP, and other complex health populations to optimize risk adjustment, clinical quality, and care management
€Collaborate with health care economics and other analytics teams required to guide and manage program direction to interpret data and extract insights that inform the health plan of clinical drivers and trends and tracks data to improve the delivery of population health care to create value for members, providers, and the health plan.
€Develop and guide the implementation of medical management programs to ensure providers deliver appropriate, high quality, cost effective health risk assessments and other clinical services that are evidence-based
€Actively support compliance functions to maintain standardized systems, policies, programs, procedures, and workflows that ensure the health plan exceeds care management, regulatory, and quality standards
€Develop effective working relationships with internal clinical team, facilitate educational and coaching opportunities for the internal clinical team, as well as establish relationships and/or consult with external agencies in pursuit of the triple aim
€Confer directly with providers regarding the care of patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions
€Partner with appropriate entities in the investigation of potential quality of care concerns and/or grievances
€Provide clinical leadership in preparation for program audits and/or certification processes
€Develop and deliver conference presentations or other presentations (written or oral) that support the health plan in a professional and effective manner
Additional Job Responsibilities:
€Participate in staff meetings, conference calls, and other meetings in-person or virtually, as required or assigned.
€Complete reports in a timely manner as requested by health plan or other leadership.
€Assist/coach/coordinate with other team members.
€Attend training sessions to acquire/enhance skills related to programs offered
€Perform other incidental and related duties as required or assigned.
€Must be able to effectively work in a fast-paced environment independently and collaboratively and adhere to strict deadlines with a quick turn-around-time

Posted: 2020-03-18 Expires: 2020-04-18

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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Complex Care Medical Director - Iselin, NJ

UnitedHealth Group
Iselin, NJ 08830

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