Medical Director, SCO and One Care Plans

Title: Medical Director, SCO and One Care Plans
Reports to: Chief Medical Officer
Classification: Medical Director
Location: Boston (Hybrid)
Job description revision number and date: V2.0; 03.17.2025

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

SCO and One Care Summary

The Senior Care Options (SCO) and One Care programs are health plan programs for dually eligible (Medicare and Medicaid) individuals (“duals”) in Massachusetts. SCO serves eligible beneficiaries aged 65 , while One Care serves duals between ages 21-64. These programs are Fully Integrated Dual-Eligible Special Needs Plans (FIDE SNP) that integrate Medicare and Medicaid benefits, along with additional support for enrollees such as integrated care teams, care managers, social supports, etc.

The Massachusetts’ Medicaid (MassHealth) agency recently conducted a procurement for health plans to offer products in these two programs, for a five-year term starting January 1, 2026. C3 submitted a bid and was selected in September 2024.

Job Summary:

The Medical Director for SCO and One Care plans will have strategic and operational responsibility for the clinical implementation and effectiveness of the organization’s newly developing SCO and One Care health plans. Reporting to C3’s Chief Medical Officer (CMO), the Medical Director will oversee and build out the plan’s nascent Utilization Management department partnering with the Director of Utilization Management to create materials, protocols, and strong reporting and oversight for the department. They will also build a clinical team inclusive of clinical expertise in Behavioral Health and LTSS (long-term services and supports) for the plans, all working closely with the VP of Care Management and their team. They will partner closely with and create workflows in partnership with other teams in the plan and larger organizations in a multi-matrixed framework. Such teams include those on Quality, Care Management, Operations, Claims Management and other departments. This Medical Director will be an early hire in this start-up health plan with an operational “go-live” date of January 01, 2026 with open enrollment beginning October 2025.

The Model of Care for the plan envisions a community-based and FQHC-governed plan dedicated to delivering high-value care for its members, working closely with the health center organizations comprising it, and focusing on getting necessary care to the patient population (finding a way to get to “yes” wherever possible and/or ensuring that members can access needed care). The Medical Director will work with the CMO and Executive Director of the SCO and One Care Plans to achieve targets on quality of care, total cost of care savings via strong population health operations, and growth opportunities throughout the organization’s business line. The

Medical Director will also partner with health center clinical leaders at C3 participating FQHCs to ensure the Model of Care and its implementation are responsive to local community needs and health center capabilities, and that the model is able to evolve to serve the needs of the SCO and One Care populations. The Medical Director serves as a key organizational leader and models collegiality in everything they do, including in interdepartmental workings.

Responsibilities:

• Stays current with evidence-based best practices and innovations in healthcare and health plan delivery that result in improved outcomes and lower total medical costs and brings those insights to the continued evolution of the SCO and One Care Plans
• Oversees the Utilization Management Department and the Director of Utilization Management ensuring that the nascent department can build out a strong portfolio of guidelines and protocols to allow for smooth delivery of services for plan patients and providers, and is accountable to the organization’s overall goals
• Participates in Utilization Management directly with review and participation in final initial decisions on UM requests where applicable and support on the handling of appeals and next steps
• Will build a clinical team of expertise necessary for the SCO and One Care populations including bringing together a clinical Behavioral Health Director and LTSS Director with the background and skillsets to conduct high-value plan operations
• The ideal candidate will oversee these teams with organizational strength and strong collegiality amongst both directly overseen teams and those worked with in a multi-matrix environment
• Serves as a partnered strategist and proponent for the development and implementation of programs, services and performance standards related to the implementation of the organization’s clinical strategies, including strategies to improve quality & patient outcomes and effectively manage total cost of care for C3 including work in our subsidiaries utilized by our health centers, Community Technology Cooperative and Community Pharmacy Cooperative, and new other emerging opportunities for growth
• Collaborates closely across multiple teams and layers of leadership, including operations, claims, clinical operations, quality, IT, analytics, policy and finance, to ensure the effectiveness of clinical initiatives, identify gaps in clinical programs and clinical strategy, and provide leadership over the development of new clinical initiatives
• Provides key analytics and interpretation and insights into clinical and cost trends to identify areas where innovations and interventions may generate significant improvement, and collaborates with the CMO to develop, prioritize, implement, and monitor interventions
• Based on observation, organizational health plan experience, on-the-ground quality improvement experience, outcomes, evidence-based background, and industry know-how, provide input on quality improvement strategies and provide implementation support into those activities. Monitors and advises on the cost and quality performance of the overall plan Model of Care and strategy
• Provides direct support where needed to the plan’s clinical operations and care management teams for consultation on challenging UM and care coordination cases, as well as the ability to partner with teams to interface with treating providers at health centers, specialist offices, and hospitals
• Works collaboratively to partner with sister teams to assess and reduce Fraud, Waste, and Abuse risks in the program
• Meets applicable regulatory and compliance standards and accreditation requirements by maintaining a continuous quality approach to necessary reporting (both create and maintain) and to aid external and internal audits
• Formulates and executes plans to course-correct where necessary
• Manages department budget
• Supports interested health centers in understanding how C3 and the health plan can support health centers clinically, in a manner that is situationally, technologically, and geographically astute
• Serves as a clinical leader, inside and outside of the company
• Serves as a trusted advisor and partner to the C3 CMO, health center CMOs, other health center clinical leaders, and to the provider ecosystem partners including hospitals and plan specialists, as well as colleagues in state and federal government
• Collaborates with policy staff to provide input on and develop organizational responses to proposed regulatory changes
• Partners with colleagues on EMR, pharmacy, and risk adjustment optimization This would, for example, include clinical input and triage input into improving EMR workflows and data and interoperability efforts in a manner that is collaborative and focused on problem-solving
• Develops relationships, sets shared goals, and holds health center and ecosystem partners accountable in working toward shared goals
• Communicates enthusiasm for the mission of C3 and the opportunity the organization represents for FQHCs and safety net populations to be successful in value-based care, and for FQHCs to serve their communities even more effectively and shares this message with both internal (e.g. C3 FQHC) and external audiences
• Supports the CMO and members of the Executive Team in analyzing, recommending, shaping, and/or monitoring changes in reimbursement rates, networks, payment policies, benefits, utilization management, and any other changes in the “rules of the road” associated with the execution of the health plans

• Supports the CMO and other team members in standing up novel new programs for value-based care in the organization’s portfolio
• Collaborates with health center CMOs to gather information related to common issues and representing policy concerns to the Massachusetts Executive Office of Health and Human Services (EOHHS) or CMS (Centers for Medicare and Medicaid services)
• Serves as supporting staff for the various committees within the plan including the Pharmacy and Therapeutics Committee, Utilization Management Committee, Quality Committee, and others. Where needed, the Medical Director will develop and present content for the committees, working with their respective board Also serves as member where needed on clinical advisory committees related to EMR and pharmacy efforts
• Alongside other staff, documents board decisions related to financial matters including the development of policies
• Together with colleagues and other senior leaders, fosters a culture (through example as well as influence) of constructive and solution-oriented collaboration to define plans of operation as this fast-moving organization continues to take on new business and changes in scope and priorities
• Is a supportive thought partner to all colleagues
• Strikes a good balance between, on the one hand, appropriately advising operational teams and pushing for proactive and lower operational risk, and on the other hand having a “can do” approach to inevitable evolution and expansion in the organization’s scope
• Other duties as assigned
• This role is expected to balance C3 duties and some form of active clinical practice, likely at the 80/20 or 90/10 ratios. The ideal candidate would be expected to conduct their clinical practice at a C3 health center site utilizing the suite of support tools provided by the ACO (including the centralized CTC EMR and quality and care coordination suites)

Required Skills:

• Must possess strong clinical, strategic, collaboration and communication skills, along with practical skills in developing, measuring and modifying clinical programs to achieve goals in a value-based care context
• Experience working in or with Federally Qualified Health Centers
• Experience in or working closely with Health Plans
• Familiarity with the MassHealth program and/or other state Medicaid programs and dual-eligible plans in particular
• Familiarity with Medicare quality programs (Part C and Part D) and dual-eligible models of care
• Familiarity with Utilization Management for surgical procedures, Medicare and MassHealth rules, Medicare Part B medications, long-term services and supports (LTSS), and home health (HH)
• Experience with alternative payment models
• Experience leading successful change in one or more clinical settings
• Experience with on-the-ground quality improvement efforts
• Experience with behavioral health, physical health, health-related social needs, and social needs of the marginalized, aging, and disabled populations
• Experience at the intersection of information technology and clinical care, and care team design/redesign relevant to the implementation of value-based care systems
• Skilled in exercising a high degree of initiative, judgment, discretion and decision-making to achieve objectives
• Strong track record of working in multidisciplinary teams that share and leverage the strengths of its members
• Strong track record of managing team(s) of direct and/or indirect senior-level administrators; engaging and developing staff
• Strong communication and persuasive skills
• Must be able to remain in a stationary position 50-75% of the time

Desired Other Skills:

• Familiarity with the MassHealth ACO program and/or other state Medicaid programs
• Familiarity with Medicare ACO programs and dual-eligible models of care
• Familiarity with Federally Qualified Health Centers
• History of accountability for an area with a high degree of regulatory compliance complexity, ideally for dually-eligible-specific compliance
• Experience with anti-racism activities, and/or lived experience with racism

Qualifications:

• Medical degree, MD or DO, required or advanced practice-equivalent alongside appropriate years of experience required
• 5-plus years of management in clinical, consulting, health plan operations, provider practice hospital leadership, or equivalent. Health plan experience is highly preferred
• Active clinical licensure in the State of Massachusetts or ability to obtain alongside active clinical practice as noted above

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **