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GENERAL SUMMARY OF POSITION: 

Under the direction of the MassHealth Chief Medical Officer/Director of the Office of Clinical Affairs (OCA), the Senior Medical Director works collaboratively across a matrixed organization to provide clinical leadership and medical management expertise in the implementation and optimization of OCA and MassHealth programs.  The Senior Medical Director collaborates with program managers in the design, development, implementation, and evaluation of clinical programs, such as prior authorization, hospital utilization management programs, care management, disease management, and program integrity.  The Senior Medical Director oversees the OCA physician staff and serves as a clinical resource for OCA programs.  The Senior Medical Director serves as a member of the OCA, MassHealth and Commonwealth Medicine leadership teams and will assume the administrative responsibilities of the MassHealth Chief Medical Officer/Director of OCA upon her request.

MAJOR RESPONSIBILITIES:

• Participate with the MassHealth Chief Medical Officer/Director of OCA and other OCA clinical leaders in strategic planning to develop and define long term clinical plans, strategies, and improvement opportunities.
• Collaborate with program managers in the design, development, implementation, and evaluation of utilization management, care management and other clinical programs as they relate to the overall delivery of health care to members.
• Provide clinical support and expertise to cost savings initiatives, credentialing, appeals, care management/disease management activities, fraud/waste/abuse efforts, and other clinical initiatives as required.
• Participate in/lead the development of policies, clinical standards, guidelines, criteria, and algorithms for use in MassHealth medical services, ensuring adherence to all applicable federal and state laws and regulations.
• Provide clinical leadership to OCA programs and clinical staff, including training and monitoring clinical staff performance on case development and utilization management decision-making.
• Analyze and interpret medical trends, utilization data and process measures to ensure that processes are in place to meet or exceed organizational goals.
• Participate in OCA activities to monitor and report upon quality, clinical effectiveness, cost effectiveness and ROI of MassHealth internal and/or vended program interventions.
• In collaboration with the Director of Medical Management and the Manager of Clinical Review Operations, assist in the identification and implementation of opportunities for improving the physician review process.
• Participate in communications with MassHealth medical providers, conduct peer-to-peer discussions, as applicable, and educate physicians and others on current policy and prior authorization issues.
• Provide clinical leadership in clinical research and analysis initiatives within OCA.
• Comprehensively understand and apply local, state and national trends in health care delivery and managed care to positively influence MassHealth policy.
• Assist in the development of system-wide data and studies of clinical standards of care to identify best practices associated with improved health outcomes and to ensure that efficient and effective programs and approaches are developed consistent with optimal clinical practice.
• Represent the MassHealth Chief Medical Officer/Director of OCA at OCA, MassHealth, Commonwealth Medicine and external meetings as requested by the MassHealth Chief Medical Officer/Director of OCA.
• Supervise, train, coach, mentor, evaluate and ensure the professional development of the OCA physician staff and other OCA staff as assigned.
• Is accountable for assigned staff’s attendance and coverage, productivity, quality and timeliness of work product, and other supervisory duties as required.
• Work collaboratively with both clinical and non-clinical team members.
• Perform other similar and related duties as required or as directed.

REQUIRED QUALIFICATIONS:

• 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 and minimum 5 years of experience in direct patient care
• 3-5 years of the experience in a recent management/supervisory role, including supervising both clinical and non-clinical staff
• Demonstrated ability to build relationships and lead multidisciplinary teams in the attainment of quantifiable goals
• Excellent written and verbal communication skills
• Proficient in the use of data analytics to identify, direct and improve the quality and efficiency of care delivered to MassHealth members

PREFERRED QUALIFICATIONS:

• An MPH, MMM, MBA, other advanced degree in business or healthcare management, or CPE is desirable.
• Experience providing direct care to disabled and/or elderly populations or working in or with managed care organizations serving these populations
• Experience in the application of state and federal Medicaid rules and regulations. 
• Utilization management and clinical policy experience is desirable

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