Develop subject matter expertise in all relevant components necessary to ensure Commercial and ASO product success. The Commercial Product Performance Management Medical Director is responsible for ongoing analysis of current performance against historical data, competitor benchmarks, and against budget. Leads the optimization of line of business specific product performance including utilization and cost trends, quality activities and performance, and risk adjustment as appropriate. Responsible for [in coordination with network, actuary, risk adjustment, quality, utilization and case management teams, as well as other key individuals] developing and implementing interventions to mitigate adverse performance.

The Commercial Product Performance Management Medical Director provides clinical expertise and support for key accounts. Leads clinical oversight of vendor activity and performance as it relates to MVP’s Commercial/ASO membership. 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.

Commercial Product Performance Management Medical Director 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 or Vermont 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.

POSITION QUALIFICATIONS

Minimum Education:

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 Experience:

Minimum of 5 years in clinical practice with evidence of leadership excellence; 3 years of experience in a managed care environment preferable

RequiredSkills:

• Ability to lead staff effectively to achieve cohesive team operation and optimum performance
• 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.

Preferred Skills:

• Knowledge of quality improvement including HEDIS, STAR, CAHPS measures is preferred.
• Knowledge of and experience with NCQA requirements is desirable.