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Location: Boston, MA
Business Unit: Commonwealth Medicine
Department: Commonwealth Medicine - Office Of Clinical Affairs - W401300
Salary Grade: ..
Union Code: Non Union Position-W60-Non Unit Professional
Num. Openings: 1
Post Date: Dec. 28, 2015
GENERAL SUMMARY OF POSITION:
Under the direction of the MassHealth CMO or his/her designee, the Senior Associate Medical Director will serve as the Medical Director for the MassHealth Accountable Communities of Health (ACH). An important component of MassHealth’s Payment and Care Delivery reform strategy is close collaboration between ACOs and Community Partners (CPs) to address social determinants of health (SDH). This position will be responsible for defining and operationalizing MassHealth’s strategy to achieve this goal of close collaboration. The Senior Associate Medical Director reports to the MassHealth Chief Medical Officer/Director of the Office of Clinical Affairs (OCA), but will work directly with the MassHealth Director of Payment and Care Delivery Innovation in support of MassHealth’s payment and care delivery reform initiatives. The Medical Director for ACH will need to define methods by which MassHealth can ensure compliance with the ACO and CP requirements, participate in ACO and CP procurement processes to ensure they meet the required criteria and design the “Flexible Services” program for ACOs. This position will also be responsible for developing a strategy for integration of social services into total cost of care (TCOC) at the end of the 5-year DSRIP period.
- Serves as the medical director for a large programmatic component of MassHealth, providing clinical leadership and expertise to OCA and EOHHS program staff.
- Provides clinical support and expertise to OCA programs and clinical staff as requested, including case development and documentation of decision-making for approval or denial of prior authorization requests.
- Assists the MassHealth CMO/Director of OCA or his/her designee in the identification and implementation of opportunities for improving the prior authorization review process (including research and documentation of physician prior authorization determinations).
- Provides clinical support and expertise to the Chronic Disease & Rehabilitation Hospital UM program, including, but not limited to, clinical review and decision making for pre-admission screening, and concurrent and conversion reviews.
- Provides clinical support and consultation to the Non-Institutional Provider Review Unit in review of medical records and assessment of vendor physician peer reviews to monitor for and detect fraud, waste and abuse.
- Provides leadership to OCA clinicians, staff and EOHHS program leadership in strategic planning to develop and define long term clinical plans, strategies, and quality improvement initiatives.
- Provides leadership and clinical expertise for state and federal health and healthcare transformation and reform policy initiatives including health system structure and payment methodologies.
- Provides leadership in the development of policies, clinical standards, evidence-based guidelines, criteria, and algorithms for use in MassHealth medical and pharmacy services, ensuring adherence to all applicable federal and state laws and regulations.
- Leads and participates in coverage decision making for emerging and existing technologies and procedures including gathering and analyzing the evidence base and developing strategies for coverage with medical necessity guidelines as indicated.
- Reviews coding and billing issues and works collaboratively with MassHealth programs in preparing responses to provider and vendor inquiries regarding coverage and coding issues.
- Participates in communications with MassHealth medical and pharmacy providers.
- Represents OCA and MassHealth at and/or leads a variety of task forces, committees, Advisory Board meetings and other OCA, MassHealth, EOHHS and Commonwealth meetings with external stakeholders as designated by the MassHealth CMO/Director of OCA or his/her designee.
- Provides leadership in clinical research and analysis initiatives within OCA programs including a focus on population health, clinical effectiveness and cost efficiency.
- Provides clinical leadership for OCA activities to monitor, report upon, and make recommendations regarding clinical effectiveness, cost effectiveness and data analytics reporting of MassHealth medical services and programs.
- Provide clinical leadership and mentoring for the OCA and MassHealth staff and work collaboratively with both clinical and non-clinical team members.
- Participates in the establishment of departmental policies, procedures and objectives.
- Perform other similar and related duties and special projects as required or as directed.
- Licensed Medical Doctor or Doctor of Osteopathy
- Actively licensed to practice medicine without restriction in Massachusetts throughout his/her employment with OCA
- Board certified in area of specialty with at least 5 years of experience in direct patient care.
- Experience providing direct care to disabled and/or elderly populations or working in or with managed care organizations (e.g. PACE, SCO, or Integrated Care Organizations (ICOs)) serving these populations, including familiarity with long-term and other community services that support them.
- Experience in medical management activities such as utilization review, clinical guideline development, quality and process improvement related to access to care and services and provider profiling and feedback.
- Experience in the application of state and federal Medicaid laws and regulations.
- A graduate degree in Public Health or Public Policy, or other advanced degree in business or healthcare, or equivalent degree, is highly desirable.
The following are some of the additional components of this particular position. The candidate will work with MassHealth to define the requirements and incentives for ACOs and CPs to perform assessment of social services needs and to align to ensure that community services are available and responsive to the needs of beneficiaries. The candidate will also refine the approach to incorporating social determinants of health into risk adjustment methods for MassHealth accountable care models.
This individual will spend about 0.6 FTE In this role and about 0.4 FTE directly supporting the Office of Clinical Affairs medical management functions.
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