Vice President, Medical Director of Clinical Programs

This is a fully remote position, open to applicants in Nevada, +4 more states.

📋 Description

• Oversee the Health Plan Medical Directors.

• Offer clinical assistance to the Health Management Utilization Management, Care Management, and Quality teams.

• Propel the creation, advocacy, and implementation of high-quality, evidence-based utilization and care management programs and processes.

• Direct programs and evaluations that facilitate effective management of medical expenses, medical quality initiatives, and outcomes, as well as programs addressing medical utilization trends, such as inpatient care, Emergency Department, Site of Care, pharmacy, and radiology.

• Achieve established clinical outcomes, affordability objectives, and growth targets.

• Collaborate closely across the Health Plan to ensure adherence to government program regulations, including the management of clinical appeals and grievances with robust clinical evidence and guidance.

• Work in partnership with Medical Directors and the Director of Medical Economics to develop analytical methods that support and evaluate strategic development and sound clinical programs.

• Provide clinical insights into data to aid in the development and assessment of tailored interventions addressing clinical trends and opportunities.

• Formulate key strategies to tackle challenges in medical expense management.

• Recognize opportunities to enhance care quality that create a competitive edge for Martin’s Point concerning the health of the populations served.

• Responsible for appropriate Utilization Management processes.

• Assist and provide clinical input into the advancement of care/utilization management, quality, and pharmacy-related programs.

• Contribute to and advise on product design and the Medicare bid processes.

• Provide guidance in areas of clinical integration related to risk adjustment.

• Act as a central leader within the Health Plan aligning medical, clinical, and operational functions to achieve cohesive and comprehensive solutions regarding Medical and Payment Policies.

• Engage actively with quality, network, and compliance teams to enhance performance.

⛳️ Requirements

• Medical Degree (MD or DO) from an accredited medical institution.

• Board Certification in the relevant discipline or specialty.

• Over 10 years of experience, including several years of clinical practice, with leadership experience and Health Plan background as a Medical Director.

• Experience in HMO/Managed Care, including Utilization and/or Quality Program management, and familiarity with peer review, case management, population health, appeals, chronic and complex disease management, HEDIS reporting, and provider relations.

• Preferred experience with STARS and RAF in the Health Plan sector.

• Government sector experience is preferred (Medicare, Medicaid, and/or Military/Tricare products).

• Prior management experience is preferred.

• Extensive knowledge and practical understanding of healthcare systems and managed care concepts.

• Familiarity with performance-based Health Plan/provider arrangements.

• Exceptional interpersonal communication and problem-solving abilities.

• Proficient in Microsoft Office applications (Outlook, Word, Excel, PowerPoint).

• Strong communication and presentation skills.

• Demonstrated presentation capabilities for both clinical and non-clinical audiences.

• Robust analytical skills with a proven grasp of healthcare utilization data and analytics.

• Ability to influence in executive environments.

• Capacity to tailor messages for various audience levels.

• Competent in making data-driven decisions, implementing solutions, and documenting measurable impacts.

• Data skills include the capability to design tracking reports for clinical and financial metrics.

• Ability to build relationships with network and community physicians and other providers.

• Demonstrates understanding and alignment with Martin’s Point Values.

• Capable of educating and promoting best practices within medical and clinical care programs.

• Skilled in leading, developing, and managing a physician team.

🏝️ Benefits

• Health insurance.

• Paid time off.

• Wellness programs.