Senior Medical Director for Affordability (Medical Cost Optimization)

Job Summary:

The Sr. Medical Director for Affordability is a physician leader and the clinical lead for Horizon BCBSNJ’s medical cost optimization (MCO) efforts. This leader is accountable for identifying, investigating, and launching MCO programs in collaboration with the MCO strategy and execution teams. They provide support and expertise to proactively outreach to, and address inquiries from, providers, facilities, clients, medical societies, and others on MCO initiatives. They provide clinical support for all Horizon BCBSNJ teams related to MCO programs.

Responsibilities:

• Define a multi-year Medical Cost Optimization (MCO) strategy to drive affordability based on Horizon BCBSNJ experience, external data, competitive intelligence and implement this strategic vision, in collaboration with the MCO Strategy Lead.
• Partner with leadership across Horizon BCBSNJ business units to identify MCO opportunities and drive progress toward operational process improvements to ensure continual, measurable improvement of the quality, compliance, and speed of execution of MCO initiatives.
• Work collaboratively with the Clinical Analytics, Medical Economics, Finance, and other teams to source and validate the sizing and clinical efficacy of MCO business cases.
• Oversee tracking, analysis and reporting of data related to MCO to support the building of business cases, ROI analyses and measurement of progress toward MCO goals.
• Direct MCO work to guide opportunity and solution evaluation and prioritization using the principles of the MCO Committee governing framework to ensure achievement of multi-year affordability, quality, and clinical outcome targets.
• Facilitation of, and participation in, MCO Committee meetings.
• Facilitate prioritization of MCO solutions in need of funding through the CPLT and DRIVE processes.
• Partner with the Medical Cost Action Planning (MCAP), Finance and Actuary teams on tracking and reporting of enterprise MCO and MCAP performance.
• Communicate MCO strategy, activity and results across HNS and the enterprise.
• Communicate MCO efforts externally to network providers and their respective trade organizations.
• Educate Horizon BCBSNJ staff on MCO tools, strategies, and programs.

Disclaimer:

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

• Requires an MD or DO with a current unrestricted license to practice medicine.
• Requires American Board of Medical Specialties (ABMS) board certification.
• Requires a minimum 5 years of clinical practice experience.
• Requires a minimum of 3 years of experience in managed care/medical management.
• Requires proficiency working with a Windows based environment including MS Office products.

Additional licensing, certifications, registrations:

• Active, unrestricted MD or DO license required, NJ license preferred.
• No CMS sanctions or sanctions by other regulatory agencies or boards.
• Must be board certified by a specialty recognized by the American Osteopathic Association or the American Board of Medical Specialties.

Knowledge:

• Requires knowledge of clinical operations within a managed care organization.
• Requires knowledge of medical cost optimization

Skills, and Abilities:

• Be adept at influencing and challenging senior management and staff.
• Manage, and lead through influence, in a highly matrixed environment.
• Must be able to develop staff and leverage team capabilities for optimal outcomes.
• Must be able to present and interact with senior leadership as necessary.
• Must be able to tailor communication and messages to diverse audiences.
• Advocates for the organization, inspiring confidence among peers regarding reliability and capability, inspiring senior leadership expectations on potential for outstanding outcomes and achievements.
• Develop Horizon BCBSNJ staff’s competences related to medical cost optimization (MCO) and executive decision-making skills.
• Requires the ability to exercise independent judgment in making decisions.
• Requires the ability to interpret and apply state and federal regulations, hospital and provider contracts and medical policy to provide guidance related to MCO.
• Must have effective verbal and written communication and presentation skills and demonstrate the ability to work well within a team.
• Requires a proven ability to innovative, be goal oriented, possess strong critical thinking skills, and exercise sound judgment.
• Requires experience with utilization management, quality, payment integrity, case management, and/or medical policy.
• Requires broad clinical skills to understand medical issues.

Travel:

• Travel within NJ/NY/PA required as needed.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware