Medical Director - Health Plan

Martin's Point Health Care; Portland (ME); On-site; USD 238,000 - 294,000; Full time

Benefits offered by this job

Comprehensive benefits

Paid time off

Volunteer time off

Job summary

Martin's Point Health Care seeks a Medical Director to provide leadership for utilization management, cost control, and clinical quality across our Health Plans. You will collaborate with Health Plan leaders to drive cost-effective, high-quality care and ensure compliance with NCQA, CMS, and TRICARE standards.

The role requires an MD/DO with board certification and experience in health plan utilization management, with a focus on improving HEDIS metrics and patient outcomes.

Qualifications

• MD/DO license active and unrestricted in Maine or NH
• Board certified physician with post-graduate patient care experience
• 2-5 years of utilization management experience in a health plan setting preferred
• Knowledge of performance-based health plan systems and care delivery models

Responsibilities

• Lead utilization & cost management and clinical quality management for the Health Plan
• Collaborate with Health Plan functions (Health Management, Quality, Network Management, Member Services, benefits & claims, Compliance)
• Perform medical necessity reviews for health plan-covered services and resolve disputes/appeals
• Contribute to annual Utilization Management, Care Management and Disease Management program descriptions
• Develop and maintain cost-management plans with Network providers and communicate findings to stakeholders
• Support Health Plan risk adjustment activities and align with Triple Aim objectives

Skills

Analytical skills

Interpersonal skills

Leadership

Education

MD/DO license

Job description

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of \"people caring for people,\" Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a \"Great Place to Work\" since 2015.Position SummaryThe Medical Director provides professional leadership and direction to the utilization & cost management and clinical quality management functions of Martin’s Point’s Health Plans. The Medical Director works collaboratively with other plan functions that interface with Medical Management such as Health Management, Quality, Network Management, Member Services, benefits & claims management, and Compliance. They assist in short and long-range program planning, quality management, and external relationships. The Medical Director reports to the VP Medical Director and works closely with the other Health Plan leaders.Job DescriptionPRIMARY DUTIES AND RESPONSIBILITIESEmployees are expected to work consistently to demonstrate the mission, vision, and core values of the organization.Serves as a key implementer of the Health Plan’s Triple Aim strategy, vigorously and accurately driving the cost management component of the Triple Aim.Responsible and accountable to the Health Plan Medical Director for helping to manage health plan medical costs by assuring clinically appropriate health care delivery for health plan products and services.Performs medical necessity reviews of requests for health plan-covered services (benefits). Reviews disputes and appeals of said services for clinical appropriateness.Contributes to case reviews to ensure the quality and safety of care and services delivered to Martin’s Point Health Plan members.Assists in the construction of the annual Utilization Management, Care Management, and Disease Management Program Descriptions and works to ensure the programs meet accreditation and regulatory standards (e.g. NCQA, CMS, TRICARE)Participates in medical policy review and policy development.Works with Informatics, Network Management, and Medical Economics to create and maintain a system where Network providers are properly assessed regarding cost management and develops a plan and schedule for communication with outliers.Develops an in-depth understanding of ACOs and contributes to their management and strategic deployment.Provides support to Health Plan risk adjustment activities as needed.Is conversant with Health Plan goals and strategic initiatives, in particular utilization and cost management goals, MLR (budget vs. actual and performance versus prior years), inpatient days/1000, SNF days/1000, and clinical quality improvement (QI) objectives, including HEDIS.POSITION QUALIFICATIONSThere are additional competencies linked to individual contributor, provider, and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.EducationMD/DOLicensure/certificationActive and unrestricted license to practice medicine in Maine or New Hampshire; or another U.S. state with eligibility to apply for and obtain additional state licensure.ExperienceBoard certified physician with post-graduate experience in direct patient care requiredMedical leadership in, or focused activity of, a Health Plan (preferred)2-5 years of Experience in utilization management in a health plan setting is preferredKnowledgeKnowledge of process improvement toolsDeep knowledge and practical understanding of Health Care systems and Managed Care conceptsKnowledge and deep commitment to performance-based Health Plan systemsSkillsGood analytic skills with the ability to identify meaningful trends and targets for improvementExcellent interpersonal skills and demonstrated ability to establish rapport and working relationships with providers, service vendors and internal staffAbilitiesDemonstrates an understanding of and alignment with Martin’s Point Values.Demonstrated ability to manage and develop staffWillingness to explore innovative methods of providing medical managementSupports the culture and models the MPHC valuesPay Range: $238,389.30 - $294,480.90 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan. In addition to base compensation, we offer a comprehensive benefits package including medical, dental, vision, retirement savings with employer contributions, paid time off (including volunteer time off!), pie day, and other employee benefits.This position is not eligible for immigration sponsorship.We are an equal opportunity/affirmative action employer.Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [e-mail] you have a question about careers at Martin’s Point Health Care? Contact us at: [e-mail]