Senior Medical Director

This is a fully remote position, open to applicants in Illinois.

📋 Description

• Oversee clinical aspects of DSNP/FIDE complex populations.

• Create and spearhead clinical strategies, objectives, initiatives, and programs tailored for DSNP/FIDE populations.

• Enhance risk adjustment, clinical quality, and care management by leveraging knowledge of healthcare delivery, utilization management, reimbursement, and treatment protocols.

• Engage in meetings and communications with the State Department of Medicaid, including in-person attendance as required.

• Collaborate with healthcare professionals, providers, regulatory bodies, advocacy organizations, members, health systems, nursing facilities, and community-based networks.

• Design and oversee medical management programs that promote evidence-based, high-quality, and cost-effective clinical services.

• Work closely with Behavioral Health, Pharmacy, member outreach, Care Management, Quality Management, Utilization Management, Compliance, and other departments.

• Develop analytical models, interpret outcomes, track trends, and formulate population health solutions in conjunction with healthcare analytics teams.

• Present findings to senior management and staff.

• Create and deliver presentations for professional conferences and other events.

• Participate in State Fair Hearings, State calls, utilization management, appeals, and front-line UM tasks as necessary.

• Consult with providers on severe, complex, or treatment-resistant illnesses through peer review and educational efforts.

• Assist with inpatient care management, clinical coverage reviews, member appeals, medical claims evaluations, and provider appeals assessments.

• Engage in team and leadership meetings at the health plan, local, state, regional, and national levels.

• Facilitate interdisciplinary care team rounds for DSNP/FIDE members.

• Mentor and coach internal clinical teams, cross-cover colleagues, consult with external agencies, and be available on call as required.

• Investigate potential quality-of-care issues and grievances.

• Support compliance functions and establish standardized systems, policies, programs, procedures, and workflows.

• Participate in both internal and external committees and quality improvement initiatives.

• Contribute to achieving HEDIS, Stars, and local state performance objectives.

• Take part in regulatory audits and assist with clinical quality, peer review, grievance, service, and certification activities.

⛳️ Requirements

• MD or DO Degree.

• Currently Board Certified in Internal Medicine, Family Medicine, or Geriatric Medicine; Board Eligible does not satisfy requirements.

• Active unrestricted board certification in an ABMS or AOA specialty.

• Licensed in IL.

• Capability to obtain licensure in New York, New Jersey, Virginia, and Michigan as necessary.

• 5+ years of clinical experience following residency.

• Minimum of three years of training in a medical specialty.

• Experience working with complex health populations and services.

• Overnight travel may be required based on business needs.

• Preferred: At least 3 years of experience in the managed care sector.

• Preferred: Experience in leading interdisciplinary teams.

• Preferred: Knowledge of evidence-based medicine and managed care principles.

• Preferred: Ability to foster relationships with network and community physicians and other providers.

• Preferred: Residency in IL or ability to travel to IL within 24 hours.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program.

• Equity award program.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.