C&S Plan Associate Medical Director - Tennessee

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The C&S Plan Associate Medical Director is accountable for ensuring top performance in clinical quality and ratings improvement, appropriate inpatient and outpatient covered-service utilization, and health care affordability for Medicaid and the Dual Special Needs Programs. The Associate Medical Director is expected to help drive integrated health system transformation by working with facilities, provider groups, and provider organizations to address issues with and improve provider network engagement. The Associate Medical Direct will support the health plan with contractual provisions, compliance, growth strategies and develop/lead focused improvement projects that are implemented and successfully managed to achieve goals.

This position reports to the Community and State plan Chief Medical Officer with a dotted line relationship to the Executive Director of Clinical Transformation. The Associate Medical Director's primary responsibilities are monitoring utilization management, appeals and grievances activities, as well as provider quality of care. The C&S Plan Associate Medical Director collaborates within the health plan as a subject matter expert with population health, quality, and operations teams as well as our shared service partners such as the provider engagement team. The Associate Medical Director may support the implementation programs to meet market needs or business goals. In addition, the Medical Director would service as a subject matter expert in quality initiatives and special projects.

The Assistant Medical Director must be located within the state of Tennessee. You will have the flexibility to telecommute.

If you reside in Tennessee, you'll enjoy the flexibility to work remotely * as you take on some tough challenges.

Primary Responsibilities:

• Oversight of health plan utilization management and appeals and grievance processes - The Associate Medical Director is the accountable owner for all Medicaid utilization management processes as well as appeals and grievances. This includes having a working relationship with the various teams in United Clinical Services as well a coordination of state lead changes which impact our clinical functions
• Clinical Excellence, Quality Standards and Service Performance - The Associate Medical Director contributes to the HEDIS and STARs process improvements and performance strategy, CAHPS and NPS improvement strategies and support necessary Health Plan accreditation activities. The Tennessee C&S health plan has a vision to deliver quality the first time, every time; the Associate Medical Director is required to help achieve or exceed all applicable HEDIS, Stars and local state performance targets and goals. The Associate Medical Director should act as an improvement catalyst for all service and quality-related efforts by influencing, participating, and communicating to the value-based program leads, network providers, or vendors the quality goals of the health plan. The Medical Director will participate regularly in clinical rounds providing clinical insight and leadership to teams while ensuring that quality and standards of care are maintained. The Associate Medical Director supports the peer review processes including Quality of Care and Quality of Service (grievance) issues and is responsible for representing the health plan and the state Medicaid partner at State-level Fair Hearings and performing plan-level member/provider grievance and appeals reviews. They will also actively lead Provider Affairs Subcommittee (PAS), Quality Management Committee (QMC) and other associated quality and/or member/provider service-focused committees
• Affordability and Quality of Care - The Associate Medical Director assists the CMO to meet affordability targets for optimal medical performance. This work is done with the Chief Medical Officer, Chief Financial Officer, and the Health Care Economics teams. This work includes using dashboards and other clinical data, looking at trends aligning these findings to the landscape of the healthcare system. In addition, the Associate Medical Director will both bring forth and execute affordability initiatives for the health plan with the advisement of the CMO
• Drive Quality in our Provider Partnerships: This works requires a close working relationship with the plan CMO, the Executive Director of Clinical Transformation, and the Vice Presidents of Quality, Population Heath, and Operations. Activities may include conducting Joint Operations Committee meetings with providers, in coordination with shared service partners, contributing to and implementing programmatic and strategic decisions, data sharing with physicians and physician groups on quality and efficiency improvement opportunities, and implementing local Health Care Affordability Initiatives. The Associate Medical Director will support the CMO for medical dental, pharmaceutical, and or social initiatives and quality programs as required to achieve the appropriate utilization, affordability, HEDIS and Star goals of the C&S Health Plan. The Associated Medical Director is accountable for building and leaning into relationships with internal and external partners to meet or exceed market requirements
• Relationship Equity and State Compliance-The Plan Medical Director maintains a solid working knowledge of all government mandates and provisions for the local C&S market, as well as working across the enterprise to implement and maintain compliant clinical programs and procedures. They participate as a SME in reviewing work plans and in operational reviews and audits. The Associate Medical Director will engage with the Tennessee provider community, medical and specialty societies, the state regulator, and other managed care organizations. The Medical Director will work collaboratively in these activities as a representative of the health plan

Skills, Experiences, Qualifications:

• Ability to support and contribute to a team that values organizational and plan success
• Demonstrate proactive, solution-oriented approaches to work efforts and drive disciplined, fact-based decisions
• Execute with discipline and urgency: drive exceptional performance, closely monitor execution, and ensure accountability for results
• Drive change and innovation though continually seeking and implementing novel solutions
• Model and demand integrity and compliance with all company policies, and local, state, and federal regulations
• Proven ability to execute and drive improvements in alignment with company and state goals
• Ability to develop relationships with network and community physicians and other providers
• Visibility and involvement in medical community
• Ability to successfully function in a matrix organization exhibiting the culture of UnitedHealthcare

Leadership Expectations:

• Lead and influence Health Plan employees by fostering teamwork and collaboration, driving employee engagement, and leveraging diversity and inclusion
• Foster strong working relationships within health plan leadership and the shared service partners
• Develop and mentor others while also building awareness to your own strengths and development needs
• Communicate and present effectively, listen actively and attentively to others, and convey genuine interest
• Play an active role in implementing innovation solutions by challenging the status quo and encouraging others to do so
• Drive sound and disciplined decisions that drive action while effectively using financial knowledge and data to manage the business
• Manage execution by delegating work to maximize productivity, exceed goals, and improve performance

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Tennessee active/unrestricted Licensed Physician; must reside in the State of Tennessee
• Active Board Certification
• Familiarity with current healthcare landscape medical issues and practices
• Basic understanding of Medicaid, Dual Special Needs health plans (DSNP)
• Proficiency with Microsoft Office applications
• Clinical, professional interest in special needs populations and fully integrated healthcare models
• Willingness to travel locally, in Tennessee, to communities where clinical partnerships require face to face interactions
• Excellent interpersonal communication skills

Preferred Qualifications:

• 5+ years clinical practice experience; solid knowledge of managed care industry and the Medicaid line of business
• 2+ years Quality management, Utilization Management, and/or Appeals and Grievance experience
• Solid leadership skills, as demonstrated by continuously improved results, team building, and effectiveness in a highly matrixed organization
• Understanding of Utilization Management and Appeals and Grievances
• Superior presentation skills for both clinical and non-clinical audiences
• Proven ability to develop relationships with network and community physicians and other providers
• Solid data analysis and interpretation skills; ability to focus on key metrics
• Solid team player and team building skills
• Creative problem-solving skills.

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.