Medicare Value-Based Care Leader (Remote-Eligible)

Excellus BCBS; Town of De Witt (NY); On-site; USD 250,000 - 375,000; Full time

Job summary

The Senior Medical Director at Excellus BCBS leads clinical strategy across value-based care, population health, and medical management to improve outcomes and control total cost of care. You collaborate with line of business leadership, network and provider contracting, actuarial, finance, quality, pharmacy, analytics, care management, and operations to drive performance and CMS compliance.

You will guide utilization management, prior authorizations, and care coordination while ensuring member

Qualifications

• MD or DO with board certification and an unrestricted NYS license.
• 3+ years as Medical Director for a health plan or equivalent.
• Ability to influence physicians, providers, executives, and cross-functional teams.
• Experience designing and supporting value-based arrangements (shared savings, risk, capitation, etc.).
• Strong analytical and financial acumen linking intervention to cost and revenue.
• Excellent verbal, written and interpersonal communication skills.
• Understanding of managed care delivery structures and applicable regulations.

Responsibilities

• Serve as a senior clinical advisor to leadership on strategy, population health, medical cost, quality, and regulatory priorities.
• Translate clinical, utilization, quality, and financial data into actionable strategies and priorities.
• Establish provider performance expectations, benchmarks, scorecards, and improvement plans.
• Provide clinical leadership for medical management programs, including utilization management and prior authorization.
• Identify opportunities to improve preventive care, chronic disease management, and medication adherence.
• Partner with Quality leadership to monitor performance against key metrics and VBP results.
• Apply CMS, NYS and NCQA requirements to support aligned business areas.
• Perform appeals and case reviews on claims and pre-authorization requests.
• For Medicare LOB: collaborate on Medicare initiatives and audits with Compliance and Regulatory Affairs.
• Uphold integrity and privacy; ensure regular attendance and perform other duties as assigned.

Skills

Leadership & influence

Analytical & financial acumen

Communication skills

CMS/NY/NCQA knowledge

Managed care / delivery structures

Travel ability

Education

MD or DO with board certification

Active NYS Medical license

Job description

The Senior Medical Director at Excellus BCBS leads clinical strategy across value-based care, population health, and medical management to improve outcomes and control total cost of care. You collaborate with line of business leadership, network and provider contracting, actuarial, finance, quality, pharmacy, analytics, care management, and operations to drive performance and CMS compliance.

You will guide utilization management, prior authorizations, and care coordination while ensuring member