Provides clinical expertise and timely first and second level clinical determinations based on MVP’s policies/procedures, state and federal guidelines, national accreditation standards, benefits interpretations, and other medical necessity criteria as necessary.
Supports MVP’s efforts to enhance business discipline of and collaboration between Utilization Management, Case Management, Appeals and other divisions of the Health Management Department to improve clinical outcomes across all business lines.
Supports Medical Operations efforts to implement and execute Quality initiatives in a highly matrixed environment. Identifies and implements initiatives in collaboration with other senior leaders to promote appropriate care quality, service utilization, medication utilization and adherence, care management, and cost control. Through matrixed leadership supports other key stakeholders such as sales and marketing, quality, operations, and others. Supports effective matrix alignments with other key stakeholders to drive Medical Operations programming. Actively participates in MVP training and medical directors’ meetings and conference calls. Provides transactional coverage outside of normal business hours on a rotational basis, including weekends. Performs other duties as assigned.
Location near one of MVPs administrative New York state locations preferred (Schenectady, Rochester, Tarrytown); telecommuting opportunities will be considered for candidates with previous successful telecommuting management experience.
Requires ability to travel during normal business hours and afterhours as needed.
Current unrestricted licensure (MD or DO) in any US state
Eligible for licensure (MD or DO) in New York State and Vermont
Board Certified in any ABMS-certified primary care or specialty practice
Minimum of 10 years in clinical practice with evidence of leadership excellence; 3 years of experience in a managed care environment preferable
• Knowledge of utilization and care management operations and alignment of these operational areas with other key stakeholders is preferred
• Strong organizational, communication, and writing skills for function in a highly matrixed environment are essential
• Ability to communicate effectively with physicians in practice and facility staff is essential.
• Ability to effectively use the computer is essential.
• Ability to critically evaluate and research the medical literature is essential.
• Knowledge of quality improvement including HEDIS, STAR, CAHPS measures is preferred.
• Knowledge of and experience with NCQA requirements is desirable.
MVP Health Care is an Affirmative Action/Equal Opportunity Employer (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at firstname.lastname@example.org.
- Job Family Medical Management/Clinical
- Pay Type Salary
- Headquarters Office, Schenectady, New York, United States of America
- Rochester Office, Rochester, New York, United States of America
- Tarrytown Office, Tarrytown, New York, United States of America