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Medical Director - UHC Community Plan of Arizona

UnitedHealth Group

Phoenix, AZ
Job Code:
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Job Details

Medical Director - UHC Community Plan of Arizona(Job Number:722344)

Clinical Services is focused on driving measurable and meaningful improvement in the use of evidence-based medicine, patient safety, practice variation and affordability. In serving our Medicare, Medicaid, and commercial members & plan sponsors, our Clinical Services teams partner with our network of physicians, hospitals and other health care professionals to achieve these goals. We are committed to our mission of helping people live healthier lives.

The C&S Plan Medical Director has accountability for ensuring that local health plan , United Clinical Services and UHC initiatives focusing on clinical excellence, quality ratings improvement, appropriate inpatient and outpatient utilization, health care affordability, health system transformation including provider network issues, mandated provisions and compliance, growth and focused improvement are implemented and successfully managed to achieve goals. This position reports to the local C&S plan CMO and has dotted line relationships to the Plan CEO, C&S Chief Medical Officer and UCS market-assigned Regional Chief Medical Officer. The C&S Plan Medical Director primary responsibilities are directed towards C&S plan activities as defined by the C&S plan CEO and also collaborates with United Clinical Services (UCS) staff including the regional Chief Medical Officer, and other market and regional matrix partners to implement programs to support and meet market C&S, UHC/UCS and line of business goals.


Major Responsibilities:



Quality and Affordability - The Plan Medical Director has primary responsibility and accountability for Medical PMPM performance and targets for the local C&S plan(s) being overseen. This will require a close working relationship with the plan CMO, local plan staff, UCS clinical operations teams as well as with the C&S and UCS national affordability team. Activities may include conducting hospital Joint Operations Committee meetings with prioritized providers in coordination with Network and UCS, contributing to--and implementing--regional Medical Cost Operating Team (MCOT) decisions, data sharing with physicians and physician groups on quality and efficiency improvement opportunities, and implementing local Health Care Affordability Initiatives. The Medical director will engaged as a clinical lead for healthcare affordability initiatives at the local market and establishing a process for sharing data with hospitals and physicians and completing peer to peer communications as required. Additionally the Plan Medical Director has primary responsibility to help support and oversee new clinical model operations including Person-Centered Care Models (PCCM), (Accountable Care Community/ACC) relationships, and new Models of Care programs such as those defined by the Center for Medicare and Medicaid Services (CMS). S/he will support the CMO, UCS and UHN initiatives and Quality Affordability Programs as required in order to achieve the appropriate inpatient and outpatient utilization and affordability goals of the C&S Health Plan and United Clinical Services/UHC. Medical Director is accountable for leading the UCS relationship- including managing the local organization to meet national requirements. The Plan Medical Director has contributing oversight responsibility of the C&S market peer review process as defined by State regulator as well as participating in or leading the Peer Review committee.



Clinical Excellence - The C&S plan Medical Director helps oversee, and contribute to, the HEDIS and STARs data collection process and local performance strategy, CAHPS improvement strategy and support necessary Health Plan accreditation activities as well as quality rating initiatives for the local CMS plan. The plan Medical Director is require to support HEDIS, Stars and local state performance measures for the Local C&S plan. This Medical director may also act in a similar capacity for Non C&S HEDIS, STARs as directed by UCS regional CMO. The Medical Director should acts as an improvement catalyst for all quality-related efforts including Center for Medicare and Medicaid Services Star initiatives. Communicate to providers on new focus and measure/process changes. The Medical Director Support all Clinical Quality initiatives and peer review processes including Quality of Care and Quality of Service issues. Participates or leads Physician Advisory Committees (PAC); Healthcare Quality Utilization Management (HQUM), Quality Management Committee (QMC) and other associated quality and/or member/provider service-focused committees.



Relationship Equity and State Compliance - The Plan Medical Director maintains a strong 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. S/he also is committed to being effectively engaged with our external constituents such as consumers/members, physicians, medical and specialty societies, hospitals and hospital associations, federal/state regulators, and market-based collaborative. The Medical Director will work collaboratively in these activities with ongoing UCS initiatives under the aegis of the Plan CMO, C&S Medical Director/CMO and the UCS Regional CMO. The Plan Medical Director will be called upon to support outward facing relationships to State regulators based upon Contract, and direction of Plan CMO, Plan President and C&S CMO and should provide clinical thought leadership with external entities and the state All public speaking and media documents must be approved by UHC’s Chief Medical Officer and Community and State’s Chief Medical Officer.


Innovation - The Plan Medical Director is expected to support the clinical interface with care providers and UHC network management colleagues in efforts to transform the health system. Local responsibilities include driving/supporting PCCM/Accountable Care Community (ACC) growth through identification of appropriate practices; initial contact and target setting, and Implementation, as well as ongoing leadership during monthly JOCs. Medical Director is accountable for oversight of the various clinical models within the market. Knowledge of Value Based contracting variants for C&S will be required. Secondary responsibility will include but not limited to, UHC’s Accountable Care Platform, clinical practice transformation, patient-centered medical homes, accountable care organizations, creative care management programs, high-performance networks and network optimization, and consumer engagement.



Growth - The Medical Director help deliver the clinical value proposition focused on quality, affordability and service, in support of growth activities of the C&S Health Plan and the plan Medical Director reviews and edits communications materials as required, and represents the voice of the market-based customer in program design. Medical Director contributes to any RFP/re-procurement activity in the state. The Plan Medical Director actively promotes positive relations with State/local regulatory authorities and Medical Societies and records such in online Physician Engagement (PEI) tool.



Focused Improvement - The Plan Medical Director is responsible for identifying opportunities through participation in regional and local Medical Cost Operating Teams or Market reviews, National MCOT. S/he actively participates in Joint Operating Committees. S/he also provides local feedback on and oversight of the performance Optum Behavioral Solutions and OptumHealth as needed. Additional responsibilities include the timely collection and entry of information into Online Engagement Survey tools and scorecards; developing action plans for sub-optimal results; and taking a supporting and/or leadership role in Quality Affordability Programs initiatives.



Grievance and Appeals - The Plan Medical Director maintains an active liaison with UCS G&A, and is responsible for representing the Local C&S plan at State-level Fair Hearings and performing plan-level member/provider grievance and appeals reviews, as necessary.

Job Clinical Analysis & Consulting
Primary Location US-AZ-Phoenix
Other Location 
Organization C&S Arizona
Schedule Full-time
Number of Openings 1
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UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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