21 days old

C&S Sr. Clinical Medical Director - Virtual

Houston, TX 77002
  • Job Code
    891508

PURPOSE OF JOB:

The Sr. Clinical Medical Director will report to the CMO of UnitedHealthcare C&S and is a key member of the Leadership Team.  On behalf of the CMO for C&S, this Sr. Clinical Medical Director will serve as the primary mentor and leader for our C&S CMOs in each market, and address core clinical regulatory and compliance issues in local markets.  The Sr. Clinical Medical Director will work with each C&S market CMO to develop and execute clinical strategies to improve our compliance, quality and affordability strategies across all our markets, working closely with our UCS shared services clinical partners.    

The position will have joint accountability with the C&S CMO for compliance in each market for clinical oversight of our membership, clinical product offerings, clinical market strategies, clinical support for RFPs, collaboration and engagement with our Shared Services clinical team particularly around Clinical Continuum efforts in each market,  new clinical program implementations, monitoring and valuing clinical outcomes and operational performance, driving affordability pipeline and performance, overseeing development and implementation of initiatives to meet Quality standards, ensuring compliance with Medicare and state Medicaid compliance standards and appropriate capital stewardship. 

This critical leadership role will also act as the liaison for critical clinical initiatives and will collaborate across the clinical organization partnering with Optum, ECS, and UCS to design and deliver on the C&S clinical outcomes such as Clinical Continuum, prior authorization policies, and inpatient care management efforts.  This role will work in a highly matrix organization and be responsible for impacting results and change without direct authority.  As the primary liaison on these critical affordability and quality initiatives across the enterprise, this role will be accountable for the success of these enterprise-wide initiatives that impact the C&S clinical strategy.,

This role will be responsible for having exceptional knowledge of Medicaid in order to understand the impact of their decisions on the desired clinical outcomes as well as strong experience in the United Health Group environment. 

 

RESPONSIBILITIES:

   Mentor and support our market level CMOs - Principal mentor and support for our market level CMOs, including recruitment, training, and ongoing mentorship and support.

o Goals

Recruit CMOs€”work with C&S market CEOs, the C&S CMO, and Human Capital partners to identify and recruit CMOs to address the specific challenges unique to each market.

Train and onboard CMOs€”while each market level CMO will report to the C&S market CEO, this role will actively support their training and onboarding.

Support and mentor CMOs€”this role will directly mentor the market C&S CMOs as providing ongoing support for each market CMO to be successful in their initiatives. 

Ensure connection of the market CMOs to the larger UHG organization, particularly our Optum and UCS Shared Services partners. 

Periodic review of the training and mentorship program to ensure effectiveness

 

   Own Market Strategies to meet the Needs of Customers - End-to-end owner of the clinical product offerings for Community & State. Own and continuously improve / update the clinical model for all programs for competitiveness, compliance, efficiency, and affordability.

o Goals

Develop clinical model for all products.  Provide strategic clinical leadership of medical staff and programs throughout C&S.  Align with shared services capabilities as much as practical and consistent with state mandates.

   DSNP

   Medicaid TANF

   Medicaid ABD/SSI

   Medicaid LTC

   MME

   Special programs - CRS, DD, etc.

Quarterly deep dive review of clinical programs with shared services and delegates to assure clinical model effectiveness.

Ongoing monitoring through agreed upon metrics.

Ensure continuously developing efficiencies in delivering clinical model by shared services and delegates.

 

   Design and Execute Programs Jointly with Shared Service Teams - Provide clinical program requirements to Shared Service Teams.  Participate in design and production oversight to efficiently and effectively deliver high quality clinical product offerings.  Partner to oversee and execute these core affordability and quality strategies, with accountability for delivering on results from these initiatives.

o Goals

Work with shared services teams in connection with each market CMO to improve our efforts on Clinical Continuum, prior authorization, and inpatient care management, in order to identify and address areas of opportunity in each market and execute on initiatives to address these areas of opportunity.

Do above by engaging with shared service teams and development.

Provide requirements and oversee program development and deployment.

On a periodic basis, report progress towards affordability and quality targets along with our shared service partners and describe pathways for improvement.

 

 

   Support RFP Process through Superior Clinical Product Design - Monitor RFPs for emerging requirements and develop product offerings that will satisfy/delight regulators and members. Work with Development to understand competitor offerings and counter with competitive and superior programs.  Develop a roadmap/pipeline of product offerings.  Directly support the RFP process through understanding and explaining existing and new clinical programs in a way that the writers can effectively and interestingly present them.

o Goals

Get ahead of RFP process with design sessions for clinical programs.  Monitor RFP requirements through working with the development organization and clinical shared services and delegates.

Develop a pipeline of programs to meet emerging RFP requirements and competitor offerings.  Bring Development into discussion around changing and evolving clinical programs requirements.

Lead efforts to develop more market-based provider-based models and community-based models to address social determinants of health.

Develop off-the-shelf programs, in collaboration with network, product and clinical shared services, for deployment to new RFPs.

   Health and Wellness

   Member incentive programs

   Provider incentive programs

   Medical Home/Accountable Care Communities

   Disease/Condition management

Translate existing and new clinical programs for RFP writers.  Assist in developing accurate descriptions.

Develop and maintain up-to-date library of clinical responses.

 

   Oversee Implementation of New Programs - Support new programs / health plan implementation through support for hiring, training, and coordination of shared services and delegates.

o Goals

Provide pre-implementation support for clinical program deployment including coordination of health plan and clinical resources and readiness review.

Provide on-site implementation support and command center participation.

Provide post-implementation support to ensure full program implementation and compliance.

 

   Monitor Value and Performance - Regularly evaluate program outcomes, quality, affordability, and operational results with shared set of metrics and hold shared services teams accountable.  Ensure that program outcomes are available to support RFP process and demonstrate value proposition.

o Goals

Establish process and metrics to continuously monitor program performance, outcomes, and ROI.

Use results to continuously improve program offerings.

Retool or replace ineffective programs.

Design/make available outcome studies to support RFP process.

 

   Affordability - Ensure total end-to-end affordability through understanding of trend and addressing value drivers.  Meet affordability commitments through Shared Services and delegates and assuring health plan implementation of network and local initiatives.  Prospect within UHC for affordability programs not yet fully implemented within C&S.  Monitor the industry for emerging affordability plays.  Develop pipeline of affordability initiatives.

o Goals

Establish affordability targets.

Ensure that shared services and delegates appropriately understand their accountability and have plans in place to meet/exceed targets.

Continuously evaluate trend and address key drivers.

Achieve targeted saving for bed days, prior auth, radiology, pharmacy, emergency room.

Continuously monitor progress toward goals and adjust as necessary.

Participate with network and operations to achieve targeted savings on UCRT, recoveries, and Fraud and Abuse.

Develop pipeline of initiatives by participating in development across the business, mining playbooks, evaluating existing UHC programs not currently deployed to C&S, evaluating competitor strategies and behaviors.

 

   Quality Performance - Ensure services are delivered to members at the highest quality standards.  Oversee and ensure development and implementation of initiatives to meet HEDIS quality standards, state bonus benchmarks, and Stars benchmarks for pay-for-performance through working with and holding Quality Shared Services accountable.  Proceed toward goal of achieving and maintaining full program NCQA accreditation.  Continuously improve CAHPS scores for members and providers.

 

   Compliance - Oversee and ensure compliance with Medicare and state Medicaid compliance standards around prior auth, utilization review, and appeals and grievances through working with and holding accountable compliance, Clinical Services, Optum, and other clinical delegates.  Lead delegate oversight committees.

 

   Capital Stewardship - Ensure deployment of capital to clinical programs to maximize returns on compliance, affordability, quality, and efficiency.

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Categories

Posted: 2020-11-03 Expires: 2020-12-03

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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C&S Sr. Clinical Medical Director - Virtual

UnitedHealth Group
Houston, TX 77002

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