Overview

Provides clinical expertise and guidance to the daily operations and administration of medical management for VNS Health Plans. Assists senior leadership in planning, directing and coordinating all medical and related activities. Participates in implementing standards of medical service and advises senior leadership on medical and administrative questions and policies as they relate to the VNS Health Plans population. Investigates and implements new medical policies based on clinical expertise, in depth data analysis and interpretation designed to improve clinical outcomes. . Serves as consultant for unusual and difficult medical cases. Participates in the QARR/HEDIS Quality Improvement Activities and utilization management of the population. Works under limited direction.

Compensation Range:$243,000.00 - $324,000.00 Annual

What We Provide

• Referral bonus opportunities     
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays   
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability    
• Employer-matched retirement saving funds   
• Personal and financial wellness programs    
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care     
• Generous tuition reimbursement for qualifying degrees   
• Opportunities for professional growth and career advancement    
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities     

What You Will do

• Provides oversight of VNS Health Plans clinical components for utilization review and decision making.
• Leads in establishing medical policies for VNS Health Plans; collaborates in the design and implementation of advanced care/case management strategies; and communicates, with providers to ensure effective quality care is being provided as needed.
• Reviews utilization, care management and behavioral health (BH) data; identifies trends and needs of the program population; and collaborates with Medical Management leadership to develop and implement plans to meet needs.
• Provides guidance and consultative services to Utilization Management (UM) and Care Management (CM) staff on issues relating to clinical services, case management, condition management, and health risk assessments. Develops solutions for complex cases, reviews prior authorizations/denial of services, and grievances and appeals. Participates in weekly care management/UM rounds for products, as applicable. Performs audits of other UM/CM physician peer reviewers.
• Provides leadership to the Quality Improvement Program and advises Health Plan leadership on the adoption and enforcement of polices concerning medical services for Health Plan members.
• Ensures compliance with relevant and applicable federal, state and local laws and regulations. Works with Compliance and Special Investigation Unit on issues related to Fraud, Waste, and Abuse of Medicare/Medicaid services.
• Collaborates with pharmacy services to review PBM activities and denial of prior authorizations, implementation of new government program policies and the monitoring for fraud, waste, abuse of drugs. Educates pharmacists on adherence, inappropriate prescribing or duplicative services. Ensures proper communication established between prescribers, MCO and pharmacists for member medication reconciliation/review.
• Ensures that Health Plan and program guidelines are adhered to in measuring adequacy, appropriateness and effectiveness of plan of care; assists in evaluating program and member service policies and procedures to help develop ways to enhance effective delivery of care and member/provider satisfaction.
• Acts as a representative of the VNS Health Plans and an advocate for the community through liaison, lecturing and promotional activities. Attends external meetings, seminars, and conferences to promote sharing of expertise and educate consumers and external providers regarding the service model.
• Establishes and fosters ongoing communication with providers in the VNS Health Plan network to understand their barriers to delivering quality care; collaborates with providers in discussing options available to help maintain best standards in practice.
• Influences and assists in the design, development, implementation and assessment of disease state management and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high-quality medical care.
• Performs clinical reviews and conducts peer to peer meetings with in-network and out of network providers.
• Conducts discussions with in-network physicians regarding medical policies, utilization management, gaps in care, claims editing, use of resources and quality.
• Performs high dollar claims, complex case reviews and participates in the appeals process as required.
• Participates in inter-rater reliability activities.
• Serves as a member of the Credentialing and Utilization Management Committees.

Qualifications

Licenses and Certifications:
Licensed to practice medicine in New York State required
Multi-state licensure preferred
Board Certification in internal or family medicine preferred
Certification in Geriatric Care preferred
Valid driver's license or NYS Non-Driver photo ID card, as determined by operational/regional needs may be required

Education:
Medical Degree required

Work Experience:
Minimum five years of experience in clinical medicine, including three years in managed care, and application of evidence based medical necessity criteria and CMS guidance required
Behavioral Health only:
Minimum five years of experience working in BH managed care settings or BH clinical settings (at least 2 years must be in a clinical setting) required
Prior experience in geriatric medicine preferred
Prior experience in a Medical Services Organization preferred
Demonstrated strong knowledge of Medicare and Medicaid regulatory and reporting requirements required
Strong communication and influential skills required
Exceptional leadership, critical thinking and decision-making skills preferred
Excellent interpersonal and persuasive communication skills required