Quality Management Director - Healthcare jobs in Levittown, NY

HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes more than 10,000 primary care and specialist physicians delivering services to over 200,000 members enrolled in Commercial, Medicare and Medicaid products. Our Management Services Organization employs over 200 skilled staff professionals dedicated to ensuring practices deliver the highest quality of care to their patients while efficiently utilizing healthcare resources.

HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care.

Interested in joining our successful Garden City Team? We are currently seeking a SVP, Medical Management MD.:

Position Summary:
The Senior Medical Director, SVP Medical Management assumes responsibility for the Medical Management Division, managing both clinical and non-clinical staff. The SVP, Medical Management will oversee the areas of Utilization Management, Care Management, and all clinical Medical Directors in the leadership activities of the department. This leadership model brings together clinical leadership and administrative strength to ensure all functions are delivered efficiently and effectively, and all outcomes are achieved. The leadership team is responsible for setting strategic direction, planning, budgeting, policy development, and business process management and improvement for all functions. While each member will have individual goals, you will work as a strong operating unit in full support of one another.
In addition to being accountable for all the responsibilities of an HCP Medical Director as outlined below, the Senior Medical Director, SVP Medical Management will also have the responsibility for managing the work of other Physician and non-physician staff within HCP, MSO. The Senior Medical Director, SVP Medical Management manages medical costs and assures appropriate and optimized health care delivery for members. They are responsible for leading the organization’s efforts to achieve excellence in healthcare cost management, quality, member experience, and improved population and member outcomes. They serve as a clinical leader for teams dedicated to one or more of quality, concurrent review, prior authorization, case management, population health, and strategic program development and implementation. The Senior Medical Director, SVP Medical Management will serve as a resource for our IPA physicians.

Essential Position Functions/Responsibilities:

• Partner with a non-physician leader to achieve function/department specific goals
• Manage physician Medical Directors and other clinical and non-clinical staff, overseeing all work activities and ensuring they are meeting all individual and departmental goals.
• Support HR and performance management functions for staff
• Support and or oversee all functions and achieve all goals of the Utilization/Care Management department, and support activities involving case and transition management, quality, risk adjustment, provider engagement and population health activities.
• Provide professional leadership and direction in the Cost management, Population Health and Quality Improvement of HCP, as measured by benchmarked performance metrics and goals.
• Work collaboratively as a clinical resource to other plan functions that interface with Medical Management such as provider relations, shared services, claims management, Business Intelligence, etc.
• Ensure members receive safe, effective, equitable, efficient, timely and patient-centered health care services within their health plan benefits.
• Carry out all medical policies and activities consistent with NCQA and other regulatory bodies.
• Participate in and/or chair clinical and other committees and work groups as assigned.
• Ensure that all medical care, medical service, and pharmacy requests are reviewed against established clinical guidelines and that approval and denial determinations are made in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
• Identify potentially unnecessary services and care delivery settings, and recommend alternatives, as appropriate.
• Ensure the timely review of Appeals of medical, behavioral and pharmacy denials against established clinical guidelines and make approval and denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
• Ensure Peer-to-Peer communication requests are responded to timely by appropriate staff
• Identify opportunities for corrective action plans to address issues and improve organizational performance.
• Collaborate with Provider Networks, Quality and Medical Management teams in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
• Collaborate with and participate in Population Health driven initiatives as required.
• Participate in the retrospective review and analysis of HCP performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs, and other sources.
• Provide periodic written and verbal reports and updates as required in the Utilization Management, Case Management and Quality Management Program descriptions.
• Assure conformance with legal and regulatory requirements; support NCQA qualification activities, including site visits and response to accrediting and regulatory agency feedback.
• Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, credentialing, provider orientation and profiling, etc.
• Conduct quality improvement and outcomes studies as directed by the state and federal regulatory agencies, and internal operating committees
• Support the grievance process ensuring a fair outcome for all members.
• Monitor member and provider satisfaction survey results and implement changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
• May be asked to chair various HCP committees, such as UM, CM, Peer Review and Credentialing.
• Promote wellness and ensure programs of prevention, education and outreach to members and providers consistent with the company’s Mission, Vision and Values.
• Perform and oversee in-service staff training and education of professional staff.
• Contribute to the development of strategic planning for existing and expanding business; recommend changes in program content in concurrence with changing markets and technologies.
• Participate in key Marketing and Public Relations activities and presentations, as necessary, to assist the marketing effort.
• Participate in after hours on-call coverage activities with other HCP colleagues
• Some evening and weekend work may be required on rare occasions

Qualification Requirements:
Skills, Knowledge, Abilities

• Must possess excellent communications skills to interface with providers, staff, and management.
• Knowledge of medical, quality improvement and UM practices in a managed care environment.
• Knowledge of regulatory and accreditation agencies and requirements
• Able to manage multiple priorities and deadlines in an expedient and decisive manner.
• Able to manage difficult peer situations arising from medical care review.
• Appreciation of cultural diversity and sensitivity towards target population.
• Up-to-date knowledge of new information and technologies in medicine, and their application to appropriate clinical management approaches, as well as computer applications, including productivity tools and Care Management Platforms.
• Must be available during normal working hours to make coverage decisions. Additional after-hours availability may be required to review emergently or urgently needed services.

Training/Education:

• MD or DO Degree
• Board Certification, required
• Unrestricted NY State License to Practice Medicine
• No current or past sanctions by any federal or state regulatory body
  

Experience:

• 5 years of clinical experience in the active practice of medicine
• 5 years of experience in medical and/or health administration activities in a managed care setting
• 2 years of management experience in a health care setting preferred
  

Salary Information::
Annual Base Compensation: $280,000 - $335,000
Bonus Incentive: Up to 20%, based on organizational performance

HealthCare Partners, MSO provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HealthCare Partners, MSO complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.