Senior Medical Director - Medicare & Value-Based Care

Excellus BCBS; Jamestown (NY); Hybrid; USD 250,000 - 375,000; Full time

Benefits offered by this job

Remote work option (case-by-case)

Job summary

Excellus BCBS seeks a Senior Medical Director to lead clinical strategy and business transformation focused on value‑based care, population health, and medical management. You will partner with leadership across networks, contracting, actuarial, and analytics to improve outcomes and total cost of care.

In this role, you will guide medical management programs, drive quality improvement, and ensure CMS/NCQA compliance while maintaining patient and member focus in a complex health plan environment.

Qualifications

• MD or DO with unrestricted NYS license.
• 3 years as Medical Director for a health plan or similar leadership role.
• Ability to influence physicians, providers, executives, and cross‑functional teams.
• Experience designing and supporting value‑based care arrangements (shared savings, risk, capitation).
• Strong analytical and financial acumen linking clinical interventions to medical expense and outcomes.
• Knowledge of CMS, NYS, NCQA requirements and evolving payment methodologies.

Responsibilities

• Provide strategic clinical leadership for medical management programs (utilization management, prior authorization, case management).
• Develop and execute clinical strategies aligned with growth, quality, and financial objectives.
• Translate clinical and utilization data into actionable priorities and improvement plans.
• Establish provider performance expectations, scorecards, and improvement strategies.
• Lead quality improvement initiatives and monitor key metrics (quality, PMPM, utilization, risk-adjusted outcomes).
• Ensure regulatory compliance with CMS, NYS, and NCQA requirements.
• Support Medicare LOB initiatives and audits in collaboration with Compliance and Legal.

Education

MD/DO with NY license

Job description

Excellus BCBS seeks a Senior Medical Director to lead clinical strategy and business transformation focused on value‑based care, population health, and medical management. You will partner with leadership across networks, contracting, actuarial, and analytics to improve outcomes and total cost of care.

In this role, you will guide medical management programs, drive quality improvement, and ensure CMS/NCQA compliance while maintaining patient and member focus in a complex health plan environment.