Capital Blue Cross

Medical Director – Population Health

Capital Blue Cross

full-time

Posted on:

Location Type: Hybrid

Location: Harrisburg • Pennsylvania • United States

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Salary

💰 $212,000 - $344,500 per year

Job Level

Lead

About the role

  • Lead clinical oversight for key MA partnerships across both internal functions such as network provider operations and external strategic partnerships with both digital and traditional clinical programs.
  • Partner across Population Health, Government Programs and Provider Network leaders to evaluate the efficacy of existing clinical programs, and design clinical and operational strategies to optimize performance.
  • Physician lead for quality management functions and market-facing representation to the provider network.
  • Engage value-based care partners to enhance performance outcomes; leading, designing and driving scalable practice & provider engagement for MA STARS, TCOC & Risk programs.
  • Thought leader influencing Medicare TCOC and affordability strategies, including utilization management (UM) trend control and UM process improvement initiatives.
  • Assist in review and implementation of UM and medical policy, including recommendations for improvements to enhance efficiency, quality and effectiveness.
  • Integrate pharmacy and medical care strategies, acting as a bridge partner with Capital’s pharmacy benefits manager and serving as internal subject matter expert on MA formulary design.
  • Leverage existing analytics tools and assist in enhancing data products as critical infrastructure to design new clinical strategies and manage the performance of existing clinical programs.
  • Work in collaboration with UM and Care Management (CM) to understand utilization trends and develop programs to address inappropriate utilization, readmissions and achieve MLR targets.
  • Chairs high-cost claimant rounds across all LOBs.
  • Clinical committee oversight including functions such as member safety, credentialing, Medicare appeals review and strategic partner Joint Operating Committees.
  • Data-driven leadership aligns CMS compliant MA strategies to mitigate regulatory compliance risk while tracking and driving progress towards Capital’s annual goals.
  • Renders medical management decisions that are member-centered, quality-first and holistically address clinical, psycho-social member needs.
  • Leads a culture of evidence-based clinical decisions through sponsorship of population health care management rounds and member case reviews.
  • Documents in medical management systems to memorialize clinical review, plan of care and coverage decisions.
  • Works with network provider partners to access and use electronic health records, periodically supporting chart reviews for MA risk strategies.
  • Support Chief Medical Officer, Vice President of Population Health and Government Programs stakeholders with other duties as assigned.

Requirements

  • A minimum of five years of clinical experience, post residency, including both inpatient and outpatient care.
  • At least three years’ experience in managed care, utilization review, and/or quality management.
  • At least three years’ experience leading clinical program design and optimization for a Medicare population.
  • At least three years’ experience applying clinical guidelines to measure, benchmark and influence provider practice patterns and population outcomes.
  • A medical degree (M.D or D.O) and active, unrestricted medical license in Pennsylvania.
  • Must obtain licensure in all Medicare markets upon hire.
  • Must be clear of any sanctions by the applicable state of Office of the Inspector General.
  • Must not be prohibited from participating in any Federally or State funded healthcare programs.
Benefits
  • Medical, Dental & Vision coverage
  • Retirement Plan
  • Generous time off including Paid Time Off, Holidays, and Volunteer time off
  • Incentive Plan
  • Tuition Reimbursement

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard skills
clinical oversightutilization managementquality managementclinical program designdata analysismedical managementevidence-based clinical decisionspopulation health managementformulary designclinical guidelines
Soft skills
leadershipcollaborationstrategic thinkinginfluencecommunicationproblem-solvingdata-driven decision makingmember-centered approachorganizational skillsthought leadership
Certifications
M.D.D.O.active medical license in Pennsylvania