CVS Health
At CVS Health, weu2019re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nationu2019s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues u2013 caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Primary Responsibilities: u2022 Responsible for clinical oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare-Medicaid Plan) u2022 Develop and lead clinical strategy and objectives for the DSNP/FIDE populations, including the development and implementation of clinical initiatives and programs to address the needs of the populations managed to improve health outcomes. u2022 Leverage extensive knowledge of health care delivery system, utilization management, reimbursement methods and treatment protocols for DSNP/MMP and other complex health populations to optimize risk adjustment, clinical quality, and care management. u2022 Actively participate in meetings and communication with the State Department of Medicaid in person as needed. u2022 Outward facing position to interact and collaborate with medical / physical professional associates, the local provider community, state regulatory agencies and advocacy groups to advance clinical excellence and the delivery of cost-efficient care. Will also interact with the members, health systems, nursing facilities, as well as home and community-based networks. Make face-to-face visits with medical / physical professional associates, the local provider community, state regulatory agencies and advocacy groups for discussions for trend discussions. Attend in-person provider and member meetings as needed. u2022 Develop and guide the implementation of Medical Management programs to ensure providers deliver appropriate, high-quality, cost-effective Health Risk Assessments and other clinical services that are evidence-based. u2022 Work collaboratively with the Behavioral Health, Pharmacy, Member Outreach, Care Management, National Quality Management, Utilization Management, Compliance, and other departments to integrate social, behavioral, and physical health and improve clinical program execution. u2022 In collaboration with health care analytics teams, develop analytical models, interpret results, and extract insights on the clinical drivers and trends and track data to improve the delivery of population health care and to create value for members, providers, and the health plan. Understand trend and create solutions. Good with data interpretation. u2022 Effectively communicate these finding to Senior Management and staff at all levels. u2022 Develop and deliver conference presentations or other presentations (written or oral) that support the health plan in a professional and effective manner. u2022 Actively participate in State Fair Hearings as needed and state calls. Understand UM and participate in UM front line work and appeals in markets as needed. u2022 Confer directly with providers regarding the care of patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions. u2022 Work with medical director teams focusing on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review, and provider appeals clinical review. u2022 Actively participate in scheduled team meetings and leadership meetings, at the health plan, local, state, regional, or national levels. u2022 Facilitate Interdisciplinary Care Team rounds for DSNP/MMP members. u2022 Develop effective working relationships with internal clinical team, facilitate educational and coaching opportunities for the internal clinical team, as well as establish relationships and/or consult with external agencies. Must be willing to cross cover for other colleagues and become mentor for other MDs as needed and be on call as needed. u2022 Partner with appropriate entities in the investigation of potential quality of care concerns and/or grievances. u2022 Actively support compliance functions to maintain standardized systems, policies, programs, procedures, and workflows that ensure the health plan exceeds care management, regulatory, and quality standards. u2022 Support the activities of other plan leadership as required or assigned. u2022 Be an active voice and participate in all internal and external committee meetings. u2022 Actively participate in quality improvement activities internal and external to the organization with multiple stakeholders. u2022 Help achieve or exceed all applicable HEDIS, Stars and local state performance targets and goals otherwise specified for the plan. Be present for regulatory audits in-person. u2022 Support all Clinical Quality initiatives and peer review processes including Quality of Care and Quality of Service (grievance) issues. u2022 Actively participate in or lead quality and/or member/provider service-focused committees. u2022 Provide clinical leadership in preparation for program audits and/or certification processes. Required Qualifications: u2022 MD or DO Degree and Currently Board Certified in Internal Medicine, Family Medicine, or Geriatric Medicine.