Vice President, Executive Medical Director

Job ID: J114321
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jan 5, 2018

Share:

Description

JOB SUMMARY (Summarizes the major purpose and primary responsibilities)

This job is accountable for the strategic direction, implementation and effective execution of physician-led functions within Clinical Services including, but not limited to, Utilization Review, Medical Policy, Member and Provider Appeals and Retrospective Review.  In addition this leader will have oversight of all Medical Director activities within Clinical Services especially those related to utilization management decision making with the intent of ensuring the delivery of high quality, cost effective, evidence-based care to the Organization's members across all products and markets. 

ESSENTIAL RESPONSIBILITIES (Describes the critical tasks, duties and responsibilities of the position.)

  • Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
  • Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.
  • Responsible for ensuring that all physician utilization management decision making is compliant with all applicable CMS and state-specific regulations and accreditation standards and that all appeals and retrospective reviews  are handled consistent with applicable regulations and standards. 
  • Responsible for setting the strategic direction around the development and maintenance of medical policies that are consistent with evidence-based medicine and fully compliant with all applicable CMS and state-specific regulations and accreditation standards. 
  • Collaborate with Government and Regulatory Compliance to develop and update business processes as necessary to ensure full compliance with all applicable  federal and state regulations.  
  • Collaborate across Clinical Services and the Organization to assess market specific care cost data to identify and implement changes to product design, provider reimbursement, medical policy, prior authorization requirements and other business processes to continuously drive toward improved care cost management, reductions in practice variation and high quality patient outcomes.
  • May partner with the CMO to act as a physician advisor for sales and client managers, legislative priorities, provider relations, media relations, FIPR, product, legal, Actuary and other key business units.
  • Participate in the identification of vendors who can effectively assist the Organization in managing care costs while also ensuring a seamless member experience. 
  • Other duties as assigned or requested.

REQUIRED EDUCATION

Doctorate Degree - Medicine

Substitutions (Acceptable substitutions in lieu of a degree 1 ½ years’ experience  = 1 year college)

MD or DO

PREFERRED EDUCATION

Master's Degree -

EXPERIENCE

Minimum: This section refers to the minimum years and type of applicable experience needed to perform the job.  Minimum requirements must be non-comparative, objective, and relevant.

  • Board Certified physician with a current, unrestricted PA medical license. 
  • 7 - 10 years' of prior medical/clinical staff leadership experience in one or more of the following:  care management, utilization management, quality or medical policy.

Preferred: This section refers to additional desired years and type of experience that the hiring manager would prefer, above and beyond the basic requirements of the job.

  • 3 years' experience in all aspects of medical cost management, care management, quality and medical policy.
  • Experience in health promotion and Patient Centered Medical Homes

KNOWLEDGE, SKILLS & ABILITIES (List the attributes required to perform the job through demonstrated service, education or training)

  • Excellent communication and public speaking skills, well-developed interpersonal skills and the ability to interact effectively with members, practitioners/providers, colleagues and local, State and Federal agencies. 
  • Proven ability to manage a project in order to accomplish previously agreed upon desired goals within a reasonable time period and through the use of developed organizational and leadership skills.

REQUIRED LICENSURE (Licenses that are required to perform the job)

Board Certified Physician with Unrestricted Medical License in the state of PA

PREFERRED LICENSURE

TRAVEL REQUIREMENT:  0%  - 25%
(List % of time traveling)

LANGUAGE REQUIREMENT (other than English)?  
(List primary language)

PHYSICAL, MENTAL DEMANDS AND WORKING CONDITIONS
(The physical, mental demands and working conditions described here are representative of those that must be met by an employee to successfully perform the essential function of their job. Reasonable accommodations will be made when necessary to enable individuals with disabilities to perform the essential duties of the position, to the extent that they do not cause undue hardship.

Position Type:

Office-Based

Office-Based Positions

An employee in this position works in an office environment.  The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email).  The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks.  The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Teaches/Trains others regularly  Frequently

Travels regularly from the office to various work sites or from site-to-site Occasionally

Works primarily out-of-the office selling products/services (Sales employees)  Does Not Apply

Physical Work Site Required  True

Most On-The-Road Positions

An employee in this position may work in a home or company office environment but is also frequently driving to and from various locations to perform the work off-site.  The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email).  The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks.  The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Non-Office-Based Positions

An employee in this position is frequently required to move throughout the workplace, sit, stand and walk, use hands and fingers to hold objects, tools or controls, possess fine motor skills (e.g., to write and operate a computer or to steer transportation equipment), possess gross motor skills (e.g., to carry items), reach with hands and arms, climb stairs and ladders, balance, stoop, kneel crouch and crawl, communicate effectively, and talk and hear. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.  The employee must be able to work in a busy environment where decisions often must be made quickly, must attend work on a regular and reliable basis, must adhere to all workplace policies, and may be called upon to work outside regular business hours.  This work occurs in a [example: warehouse, hospital or provider’s office or mailroom].

Lifting: up to 10 pounds   Occasionally

Lifting: 10 to 25 pounds Rarely

Lifting: 25 to 50 pounds Never

ADDITIONAL INFORMATION

Changes Approved By:

Lesa Leverett

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

Share:

Interested in working at the Highmark Health enterprise?
Take the first step by joining our Talent Network today!

Join Our Talent Network

Similar Jobs

Case Mgr LTC - Gateway

Home, DE, United States
Clinical Services

Supervisor Case Management

Home, DE, United States
Clinical Services

Intake Coordinator

Charleston, WV, United States
Clinical Services

Medical Case Manager-3

Home, DE, United States
Clinical Services

Onboarding and Learning Specialist

Pittsburgh, PA, United States
Clinical Services

Enhanced Community Care Manager, RN

Carnegie, PA, United States
Clinical Services

Care Coordinator Arkansas

Home, AR, United States
Clinical Services

Enhanced Complex Care Manager RN

Wexford, PA, United States
Clinical Services

Social Worker

Pittsburgh, PA, United States
Clinical Services

Enhanced Community Care Manager, RN

Natrona Heights, PA, United States
Clinical Services

Supervisor Intake Coordination

Charleston, WV, United States
Clinical Services

Enhanced Community Care Manager, RN

Erie, PA, United States
Clinical Services

Complex Care Manager RN

Home, PA, United States
Clinical Services

Behavioral Health Specialist-6

Pittsburgh, PA, United States
Clinical Services

Embedded Case Manager RN

Pittsburgh, PA, United States
Clinical Services

Medical Director Position

Wilmington, DE, United States
Clinical Services

Supervisor, LTSS Case Management

Home, DE, United States
Clinical Services

Manager, LTSS Case Management

Home, DE, United States
Clinical Services

Medical Review Clinician

Home, PA, United States
Clinical Services

Behavioral Health Specialist-2

Pittsburgh, PA, United States
Clinical Services

Medical Review Clinician-2

Home, PA, United States
Clinical Services

ltss case manager-11

Home, DE, United States
Clinical Services

Associate Medical Director

Home, WV, United States
Clinical Services

Medical Case Manager - GHP

Home, DE, United States
Clinical Services

Enhanced Community Care Manager - RN

Camp Hill, PA, United States
Clinical Services