Virginia Premier Health Plan Sr. Medical Director in Glen Allen, Virginia

About Us

Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.

By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.

At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.

If this sounds like you, read on!

Overview

The Senior Medical Director will have direct responsibility for supporting medical management activities for all lines of business to include Medical Payment Policies, UM, CM, and Quality Improvement. Will manage a team of Medical Directors and coordinate with internal and external partners to ensure appropriate utilization of services and quality of care.

In addition to the responsibility for oversight and performance of Medical Management, and Quality Improvements. Will also contribute to improving the healthcare delivery system to ensure not only cost-effective medical care, but also achieve and maintain high quality standards, such as those required by NCQA as well as State and Federal regulators.

Responsibilities

  • Provides oversight of the medical utilization management activities, including all case management, referral management and the evaluation of all cost-recovery cases

  • Provides support and oversight of the clinical activities for the Medical Directors excluding Behavioral Health and the Neighborhood Health Center

  • Provides oversight of the quality assessment and improvement activities including clinical outcomes, preventive services and accessibility to quality services, medical records reviews as well as mobility and mortality reviews

  • Provides on-going management, development and maintenance of clinical practice and preventive guidelines

  • Serves as a resource for utilization management nurse coordinators for activities involving care management and care coordination for members requiring both ambulatory and inpatient services

  • Ensures clinical compliance with the appropriate State and Federal standards

  • Develops, implements and provides medical interpretation of medical policies, procedures and benefit document language to guide and support the provision of medical care and clinical coverage review in partnership with the Chief Medical Officer

  • Assists Network Development with provider recruitment activities

  • Actively participates and provides strategic guidance in health plan committee meetings and taskforces i.e. HQUM, P&T, QIC, Credentialing etc.

  • Conducts ongoing review and investigation of provider performance in their provision of healthcare to members

  • Maintains active communication with internal stakeholders on decisions regarding UM, Appeals, benefit interpretations as well as provider access and availability standards, network adequacy and quality of care issues

  • Actively participates in team meetings focused on communication, feedback, problem-solving, process improvement, staff training and evaluation, and the sharing of program results

  • Represents Virginia Premier in designated local and state meetings as needed

  • Oversees and manages the Inter-Rater Reliability (IRR) process for the Medical Directors

Qualifications

MINIMUM EDUCATION REQUIREMENTS

  • Graduate as a Medical Doctor from an accredited College of Medicine

  • Board certified physician preferred

  • Current and unrestricted Virginia Medical license

WORK BACKGROUND/EXPERIENCE

  • Minimum of 7 years clinical experience

  • Minimum of 3 years of experience in managed care and medical management of health plans or in medical programs administration

  • Experience developing and/or implementing practice guidelines

  • Demonstrated leadership with experience managing and developing a team

  • Prior experience utilizing technology and leveraging data to drive medical management initiatives around the metrics and analytics of population management (i.e. identifying trends, predictive modeling etc.)

  • Demonstrated experience directing utilization management, utilization review, credentialing and quality activities with hospital organizations, HMOs, and provider groups

  • Experience with Medicaid and Medicare programs preferred

SPECIAL KNOWLEDGE AND/OR SKILLS

  • Comprehensive knowledge of Utilization Review Principles and Criteria (InterQual, Milliman, Hayes, etc.)

  • Knowledge of HEDIS, Stars and other quality measures.

  • Excellent communication, interpersonal and analytical skills

  • Ability to communicate effectively with others

  • Ability to work independently as a key member of the management team and to help set priorities

  • Ability to work effectively and influence decisions in a cross-functional team environment

  • Demonstrated commitment to ensure clinical programs are culturally sensitive and linguistically competent

  • Team building skills and able to build consensus and to affiliate with and collaborate toward organizational objectives

  • Able to foster effective interactions across organizational and department leaders and teams

  • Excellent presentation skills, able to present organizational objectives, ideas and/or concepts in a professional and credible manner

PHYSICAL REQUIREMENTS

  • Physical health sufficient to meet the ergonomic standards and demands of the position.

All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

Our mission is to inspire healthy living within the communities we serve!

Job ID 2018-5150

As an equal opportunity employer, Virginia Premier is committed to a diverse workforce. To ensure non-discrimination and affirmative action for individuals protected by Executive Order 11246, as amended, Section 503 of the Rehabilitation Act of 1973, as amended, the Vietnam Veterans’ Readjustment Act of 1974, as amended, and Title I of the Americans with Disabilities Act of 1990, as amended, Virginia Premier will consider applicants for employment without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. Applicants who require accommodation in the job application process may contact Recruitment at 804-819-5151 for assistance. It is the policy of Virginia Premier Health Plan, Inc., to comply with the requirements of the Drug-Free Workplace Act of 1988. It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants in our workplace. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Virginia Premier participates in E-verify.