Senior Medical Director, Medicare – Value-Based Payment

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

📋 Description

• Act as a senior clinical advisor to business leadership regarding strategy, population health, medical expenses, quality, and regulatory priorities.

• Formulate and implement clinical strategies that align with the organization's growth, quality, and financial goals.

• Convert clinical, utilization, quality, and financial data into actionable plans and operational priorities.

• Set provider performance expectations, establish clinical benchmarks, scorecards, and strategies for improvement.

• Offer clinical leadership in areas such as utilization management, prior authorization, concurrent review, case management, and care coordination.

• Enhance site of care efficiency and minimize avoidable inpatient admissions, readmissions, emergency department usage, and unnecessary high-cost services.

• Advance preventive care, chronic disease management, medication compliance, member experience, and quality metrics.

• Collaborate with Quality leadership on initiatives for quality improvement and monitor medical expenses, PMPM trends, utilization, risk-adjusted performance, quality, and VBP outcomes.

• Utilize knowledge of CMS, NYS, NCQA, federal regulations, payment, and quality methodologies.

• Conduct appeals and case reviews regarding claims and pre-authorization requests.

• For the Medicare line of business, work with Compliance, Legal, and Regulatory Affairs on initiatives and audits.

• Partner with business leadership, contracting, actuarial, finance, quality, pharmacy, analytics, care management, and operations.

• Uphold member privacy, integrity, attendance, and adherence to organizational values and policies.

• Execute additional tasks as assigned by management.

⛳️ Requirements

• M.D. or D.O. degree in medicine is required.

• Board certification is mandatory.

• An unrestricted active NYS Medical license is necessary.

• A minimum of three (3) years of experience as a Medical Director for a health plan or equivalent experience is required.

• Experience in designing and supporting shared savings, shared risk, capitation, global risk, bundled payment, and other value-based arrangements in MA is essential.

• Strong analytical and financial skills are required.

• A solid understanding of managed care and healthcare delivery systems is necessary.

• Familiarity with CMS, NYS, NCQA requirements, applicable federal regulations, and evolving payment and quality methodologies is required.

• For the Medicare line of business only: at least 5 years of progressive leadership experience in Medicare Advantage, managed care, population health, health plans, ACOs, provider organizations, or similar environments is essential.

• Extensive experience in Medicare Advantage is necessary.

• Expertise in the economics of Medicare Advantage and risk-based populations is required.

• Strong knowledge of Medicare risk adjustment, CMS-HCC methodology, clinical documentation, and RADV requirements is essential.

• Willingness to travel throughout the Health Plan service region is necessary.

• A valid Class D license and the ability to drive a motor vehicle are required.

🏝️ Benefits

• Group health and/or dental insurance.

• Retirement plan.

• Wellness program.

• Paid time away from work.

• Paid holidays.

• Potential for remote work, assessed on a case-by-case basis.