Note: We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

PURPOSE: 

• Leads the organization's efforts to achieve excellence in healthcare affordability, quality, member experience, and improved population and member outcomes in both commercial and government program lines of business. Through deep operational and clinical expertise, drives the company-wide Quality Management program (including CMS Stars and risk adjustment), and the ongoing development and implementation of health care policy and technology assessment. 

• Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan members, targeting improvements in efficiency and satisfaction for members and providers. Serves as a clinical advisor/leader for teams dedicated to concurrent review, prior authorization, case management, disease management and clinical coverage review. Represents CareFirst in state and local level workgroups, task forces, and committees that address medical quality and cost.  Garners relationships and interface with external parties such as medical societies, hospital CMOs and VPs of Medical Affairs in health systems and large medial groups.  Influences various parties in the health care public policy arena supporting the CareFirst legislative agenda and being part of committees often where CareFirst is the only insurer called to the table.

• Collaborates with other senior leaders on efforts that enhance the quality-of-care delivery, improve outcomes, and improve value delivered to our members and accounts.

ESSENTIAL FUNCTIONS:

Clinical Physician Executive Leader

• The Vice President and Chief Medical Officer has the primary responsibility, as the lead physician executive for the Corporation, to provide strategic clinical direction for all programs promoting health equity, improved quality of care and managing cost of care. This role includes providing expert clinical consultation to executives throughout the organization. Provides oversight and direction to for a team of physicians dedicated to CareFirsts mission to drive affordability, access, quality and equity in healthcare. Plays a highly influential and advisory role providing clinical and quality direction and oversight to care support programs. Contributes to the development of strategic planning for existing and expanding business; recommends changes in program content in concurrence with changing markets and technologies. Assist as a strategist and counselor to CareFirsts corporate development and innovation team; participate in the assessment of strategic acquisitions which close current service offering gaps. Serves as medical subject matter expert, providing scientific/medical guidance to business initiatives/investments with the lens of the customer/patient experience. May be asked to chair or be thought leader on various health plan committees and task forces both internal and external. 

• Represents CareFirst, as lead physician and clinical spokesperson to key local and national stakeholders, and to key regulatory entities. This includes the BlueCross BlueShield Association, Maryland Health Care Commission (several work groups), Maryland Patient Safety Center, the Maryland medical society (MedChi), among others.

Medical Policy and Utilization Management Infrastructure

• Oversees the Medical Policy team and adoption of national standard, evidence-based clinical guidelines to the extent possible. Develops, defines and recommends uniform medical policy with consistent application and care guidelines for the company. Oversees and directs the rendering of medical management decisions at all levels of the health plan that maximize benefits for our members while pursuing and supporting corporate objectives and maintaining compliance with regulatory bodies. Provides direction and oversight to all doctoral level professionals in the Health Services area, including those involved in medical necessity reviews, health care policy and technology assessment processes. 

Provides support and a clinical escalation path to care management and utilization management staff, including RNs and non-professional staff, who maintain a Care Management information system, conduct medical necessity and benefit determinations for medical services (pre-service, concurrent and retrospective), appeals, and medical underwriting. These ensure that members receive the right care at the right time in the right setting at the right cost.

Inpatient Management Oversight

• Leads a team of clinical and non-clinical staff to manage the inpatient experience for CareFirst Members at hospitals in Maryland using a per diem methodology and at hospitals in the rest of the United States using a diagnostic related group (DRG) methodology.  These teams will assure Members have the appropriate length of stay, level of care, and that they achieve optimal clinical results upon discharge.  

SUPERVISORY RESPONSIBILITY:

This position manages people.

QUALIFICATIONS:

Education Level: Medical Degree in Medical degree in primary care specialty from an accredited medical school and an American residency in a primary care specialty. Must have current medical license in the State of Maryland (or credentials to apply for and be granted a Maryland license). Must have board certification.

Experience: 

• Minimum of 8 years clinical and administrative experience in a managed care setting.

• Previous experience as medical director for a health care company.

• At least 5 years as a leader of people and teams.

Preferred Qualifications:

• In-depth knowledge of Medicaid and Medicare related programs in a health plan/payor environment, with solid understanding of Stars and risk adjustment.

• Prior experience with operations management.

• Previous experience collaborating with formal health economics function within corporate environment.

• Ability to expand in scope and clinical leadership oversight as business needs evolve.

Knowledge, Skills and Abilities (KSAs)

• Must possess excellent verbal and written communication skills.  Knowledge and experience in utilization management and quality assurance.

• Understanding of federal and state regulatory processes.

• Knowledge and experience with national standard, evidence-based clinical guidelines.

• Demonstrated leadership effectiveness in both formal and influencer roles; dynamic leader that motivates and inspires teams to achieve challenging targets and can interact effectively in matrixed environment.

• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.