The Senior Clinical Director for Medical Management will lead medical management strategy and operations for the MassHealth Office of Clinical Affairs to ensure the delivery of medically necessary, cost-effective, and high quality care for MassHealth members. Working closely with clinical and operational leaders within the Office of Clinical Affairs, this leader will oversee program initiatives related to utilization management (including prior authorizations), medical coverage policy, and care management.
Responsibilities:•Leads development and implementation of Office of Clinical Affairs strategy for medical management to ensure appropriate, efficient, and high quality care delivery
•Collects, analyzes and reports on medical management metrics to identify trends and recommend interventions
•Accountable to improving efficiency, cost-effectiveness, and quality in OCA’s medical management programs, including through use of new technology as appropriate
•Contributes to MassHealth’s cross-agency medical management strategy
•Oversees Office of Clinical Affairs Medical Management Programs and functions
•Oversees and contributes to OCA utilization management initiatives, including related to prior authorization, concurrent review, and retrospective review
•Oversees and contributes to development and implementation of clinical coverage policies, including assessment of new and existing technologies.
•Oversees and contributes to clinical reviews of providers
•Reviews, analyzes, and responds to quality and safety data
•Ensures high-performing medical management programs that adhere to all relevant regulatory and other requirements, including those set forth by CMS and other oversight entities
•Advises and collaborates with the Chief Medical Officer (CMO) and Medical/Clinical Directors on strategic issues involving medical management programs
•Serves as a lead interface for OCA medical management programs with other teams throughout the agency
•Leads and/or supports external stakeholder engagements regarding coverage and medical management of services for MassHealth members
•Manages clinical and non-clinical staff who are directly responsible for executing on OCA’s medical management initiatives
•Ensures Medical Management staff maintain up-to-date knowledge, skills and abilities related to the administration of assigned responsibilities and functions
•Oversees relevant contractors performing utilization management reviews on behalf of OCA/MassHealth
•May engage in other clinical policies and program work within the MassHealth portfolio
•Other duties as assigned
LICENSURE/CERTIFICATION:
•Current, unrestricted R.N., C.N.P, or P.A. license in Massachusetts throughout employment with OCA
REQUIRED EDUCATION:
Bachelor’s degree required
REQUIRED QUALIFICATIONS:
•At least 5 years experience in direct patient care
•At least 5 years experience in a leadership position in utilization/medical management in a managed care organization/health plan
•At least 5 years experience supervising clinical staff
•Thorough knowledge of the principles and practices of medical management including utilization management
•Excellent oral and written communication and presentation skills
•Must work 1-2 days per week on site in Boston and/or Quincy during normal business hours
PREFERRED QUALIFICATIONS:
•Demonstrated commitment to serving Medicaid patients
•Thorough knowledge of Medicaid and related regulations
•Certification in case management and/or utilization management