– Medical Director - C&S Community Plan of Kentucky –

The C&S Plan Medical Officer has accountability for ensuring that local health plan, United Clinical Services and UHC initiatives focusing on clinical excellence, quality ratings improvement, appropriate inpatient and outpatient utilization, health care affordability, health system transformation including provider network issues, mandated provisions and compliance, growth and focused improvement are implemented and successfully managed to achieve goals. This position reports to the local C&S CEO,and has dotted line relationships to the C&S Chief Medical Officer and UCS market-assigned Regional Chief Medical Officer. The C&S Plan Medical Director’s primary responsibilities are directed towards C&S plan activities as defined by the C&S plan CEO and also collaborates with United Clinical Services (UCS) staff including the Chief Medical Officer, and other market and regional matrix partners to implement programs to support and meet market C&S, UCS/ UHC and line of business goals.
Primary Responsibilities:
• Quality and Affordability – The Plan Medical Director has primary responsibility and accountability for Total Medical PMPM performance and targets for the local C&S plan. This will require a close working relationship with UCS clinical operations teams as well as with the C&S and UCS national affordability team. Activities will include conducting hospital Joint Operations Committee meetings with Network, contributing to--and implementing--regional Medical Cost Operating Team (MCOT) decisions, data sharing with physicians and physician groups on quality and efficiency improvement opportunities, and implementing local Health Care Affordability Initiatives. The Medical director will serve as clinical lead for healthcare affordability initiatives at the local market and establishing a process for sharing data with hospitals and physicians and completing peer to peer communications as required. Additionally, the Plan Medical Director has primary responsibility to oversee new clinical model operations including ACC Accountable Care Community relationships, Target setting JOC leadership. Support UHN initiatives and Quality Affordability Programs as required in order to achieve the appropriate inpatient and outpatient utilization and affordability goals of the C&S Health Plan and United Clinical Services/ UHC. The Plan Medical Director has oversight responsibility of the C&S market peer review process as defined by State regulator as well as participating in or leading the Peer Review committee.
• Clinical Excellence – The C&S plan Medical Director helps oversee the HEDIS data collection process, achievement of the contractually required clinical Quality Performance Indicators, STARs clinical collection process, CAHPS improvement, and drive Health Plan accreditation activities as well as quality rating initiatives for the local C&S plan. The plan Medical Director is accountable for HEDIS and Stars performance for the Local C&S plan. Acts as an improvement catalyst for all quality-related efforts including Center for Medicare and Medicaid Services Star initiatives. Communicates to providers on new focus and measure/process changes. Supports all Clinical Quality initiatives and peer review processes including Quality of Care and Quality of Service issues.
• Relationship Equity and State Compliance - The Plan Medical Director maintains a strong working knowledge of all government mandates and provisions for the local C&S market, as well as working across the enterprise to implement and maintain compliant clinical programs and procedures. S/he also is committed to being effectively engaged with our external constituents such as consumers/members, physicians, medical and specialty societies, hospitals and hospital associations, federal/state regulators, and market-based collaborative. The Medical Director will work collaboratively in these activities with ongoing UCS initiatives under the aegis of UCS Regional CMO. The Plan Medical Director will be the outward face to State regulators based upon Contract, and direction of Plan CEO and C&S CMO.
• Innovation - The Plan Medical Director leads the clinical interface with care providers and UHC network management colleagues in efforts to transform the health system. Primary local responsibility is to drive Accountable Care Community (ACC) growth through identification of appropriate practices; initial contact and target setting, and Implementation, as well as ongoing leadership of monthly JOCs. Knowledge of Value Based contracting variants for C&S will be essential Secondary responsibility will include but not limited to, UHC’s Accountable Care Platform, clinical practice transformation, patient-centered medical homes, accountable care organizations, creative care management programs, high-performance networks and network optimization, consumer engagement. Growth – This medical director delivers the clinical value proposition focused on quality, affordability and service, in support of growth activities of the C&S Health Plan and the plan CMO reviews and edits communications materials as required and represents the voice of the market-based customer in program design. The Plan Medical Director actively promotes positive relations with State/local regulatory authorities and Medical Societies and records such in P.E.I. tool
• Focused Improvement –The Plan Medical Director is responsible for identifying opportunities through participation in regional and local Medical Cost Operating Teams or Market reviews and National MCOT. S/he actively participates in Joint Operating Committees. S/he also provides local feedback on and oversight of the performance of Optum Behavioral Solutions and OptumHealth as needed. This role also has oversite of the pharmacy program and interacts with Optum RX and local pharmacy staff. Additional responsibilities include the timely collection and entry of information into Online Engagement Survey tools and scorecards; developing action plans for sub-optimal results; and taking a leadership role in Quality Affordability Programs initiatives.
• Grievance and Appeals - the Plan Medical Director maintains an active liaison with UCS Grievance & Appeals and is responsible for representing the Local C&S plan at State Fair Hearings.
Demonstrable Skills and Experiences:
• Ability to build a team that values organizational and Plan success over personal success; provide ongoing coaching and feedback to ensure peak performance; identify and invest in high-potentials; actively manage underperformance
• Focus staff on the company's mission; inspire superior performance; ensure understanding of strategic context; set clear performance goals; focus energy on serving the customer; provide ongoing communication to the team; discontinue non-critical efforts
• Drive disciplined fact-based decisions
• Execute with discipline and urgency: Drive exceptional performance; deliver value to the customer; closely monitor execution; drive operational excellence; get directly involved when needed; actively manage financial performance; balance speed with analysis; ensure accountability for results
• Drive change and innovation though continually seeking and implementing innovative solutions; create a culture that thrives on continuous change; inspire people to stretch beyond their comfort zone; take well-reasoned risk; challenge "the way it has always been done"; change direction as required
• Model and demand integrity and compliance
• Has a positive, flexible and informed account management approach when working with members of the NE Department of Health and Human Services
• Proven ability to execute and drive improvements against stated goals
• Ability to develop relationships with network and community physicians and other providers
• Visibility and involvement in medical community
• Ability to successfully function in a matrix organization
Leadership Expectations:
• Deliver value to members by optimizing the member experience and maximizing member growth and retention
• Lead and influence Health Plan employees by fostering teamwork and collaboration, driving employee engagement and leveraging diversity and inclusion
• Develop and mentor others while also building awareness to your own strengths and development needs
• Influence and negotiate effectively to arrive at win-win solutions
• Communicate and present effectively, listen actively and attentively to others, and convey genuine interest
• Lead change and innovation by demonstrating emotional resilience, managing change by proactively communicating the case for change and promoting a culture that thrives on change
• Play an active role in implementing innovation solutions by challenging the status quo and encouraging others to do so
• Drive sound and disciplined decisions that drive action while effectively using financial knowledge and data to manage the business
• Drive high-quality execution and operational excellence by communicating clear directions and expectations
• Manage execution by delegating work to maximize productivity, exceed goals and improve performance

Required Qualifications:

• Licensed unrestricted Medical license in the state of Kentucky
• Licensed physician; Board Certified in an ABMS or AOBMS specialty
• 5+ years clinical practice experience; strong knowledge of managed care industry and the Medicaid line of business
• 2+ years Quality management experience
• An individual staff member may not occupy more than two (2) key staff positions listed below unless prior approval is obtained from MLTC. Exceptions include the Chief Executive Officer (CEO) and Medical Director (MD), who may only hold one (1) position. Experience in Value Based Contracting / Risk contracting
• Familiarity with current medical issues and practices
• Proven ability to develop relationships with network and community physicians and other providers
• Excellent project management skills
• Proficiency with Microsoft Office applications
• The Medical Director must be a currently practicing physician, with an unrestricted license in the State to practice medicine. The Medical Director must have a minimum of three (3) years of training in a medical specialty and five (5) years of experience providing clinical services. The Medical Director must devote a minimum of 40 hours per week to the MCO’s operations to ensure timely medical decisions, including after-hours consultation as needed. The Medical Director must be board certified in his/her specialty, and be actively involved in all major clinical, utilization management and quality management decisions of the MCO. When the Medical Director is unavailable, the MCO must have a physician staff person or subcontractor to provide competent medical direction at any time.
• The Medical Director is responsible for:
• Developing, implementing, and interpreting medical policies and procedures. Duties may include, but are not limited to: service authorizations, claims review, discharge planning, credentialing, referral management, and medical review of grievances and appeals.
• Administrating the medical management activities of the MCO.
• Participating via telephone or in person (at MLTC's discretion) at every Quality meeting with MLTC and other system partners, and as requested by MLTC.
• Leading the Utilization Management, Quality Assessment and Performance Improvement, Credentialing, and Provider Advisory committees.

Preferred Qualifications:
• Excellent interpersonal communication skills
• Superior presentation skills for both clinical and non-clinical audiences
• Solid data analysis and interpretation skills; ability to focus on key metrics
• Strong team player and team building skills
• Strategic thinking with proven ability to communicate a vision and drive results
• Solid negotiation and conflict management skills
• Creative problem solving skills

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