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Senior Medical Director- Quality at Evolent Health

Senior Medical Director- Quality

Evolent Health Atlanta, GA Full-Time
**Your Future Evolves Here**

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Evolenteers make a difference wherever they are, whether it is at a medical center, in the office, or while working from home across 48 states. We empower you to work from where you work best, which makes juggling careers, families, and social lives so much easier. Through our recognition programs, we also highlight employees who live our values, give back to our communities each year, and are champions for bringing their whole selves to work each day. If you're looking for a place where your work can be personally and professionally rewarding, don't just join a company with a mission. Join a mission with a company behind it.

**Why We're Worth the Application:**

+ We continue to grow year over year.

+ Recognized as a leader in driving important diversity, equity, and inclusion (DE&I) efforts ([ Link removed ] - Click here to apply to Senior Medical Director- Quality .

+ Achieved a 100% score two years in a row on the Human Rights Campaign's Corporate Equality Index making us a best place to work for LGBTQ+ equality.

+ Named to Parity.org's 2020 list of the best companies for women to advance ([ Link removed ] - Click here to apply to Senior Medical Director- Quality .

+ Continued to prioritize the employee experience and achieved an 87% overall engagement score on our last employee survey.

+ Published an annual DE&I report ([ Link removed ] - Click here to apply to Senior Medical Director- Quality to share our progress on how we're building an equitable workplace.

**What You'll Be Doing:**

**Senior Medical Director- Quality**

**Who will you be working with:**

**In this role, you will join the Evolent Senior Medical director team, which is made up of three leaders with each individual leading predominantly in Operations, Quality, and Behavioral. These leaders also ensure appropriate utilization and innovative clinical programs for Evolent's clients' members.**

**Quality Leader**

**The Senior Medical Director- Quality (SMDQ) primary responsibility is ensuring that the work products of the medical directors consistently meet internal, client and regulatory standards. The SMDQ leads quality and the development of processes and measurement tools that support the delivery of repeatable, high-quality results for members, clients, and the enterprise. The SMDQ's time is divided 33/67 between leadership duties and working directly in an operating capacity.**

**Provide leadership for all quality management and quality improvement programs including establishment of policies, procedures, protocols and systems to support and promote the consistent delivery of high-quality medical care and optimization of member health.**

**Ensure compliance with legal requirements and regulatory/accrediting agencies' standards and procedures through the oversight of regulatory (e.g., State, Federal) and accreditation (e.g., NCQA) reviews related to utilization and quality management.**

**Provide leadership oversight for the Medical Policy Committee (MPC)**

**Provide leadership oversight for the quality meetings in conjunction with the clinical leader team**

**Provide leadership for case management programs, population health programs, utilization management programs, program quality and support, clinical program innovation, and program administration and governance**

**Provide leadership oversight for clinical data capture, analysis and reporting activities. Provide input for development of benchmarking data/standards, evaluation mechanisms, outcome measurements and clinical systems innovations.**

**Provides leadership assistance and support for provider relations, network development and provider quality activities in conjunction with the Market team. These duties may include: strengthening of provider communications, improving clinical linkages and relationships with network providers, and developing an accountable high-quality and committed provider network with aligned incentives.**

**Drives strategy, evaluates and ensures systems and processes are in place to assist providers with adherence to evidence-based protocols which may include, QA and IRR reviews.**

**Understands and drives physician related compliance to Federal (e.g., CMS), State (e.g., Insurance commission) and local rules and regulations, develops appropriate policies, procedures, and workflows are designed and trained and implemented with end-to-end execution.**

**Responsible for executing and maintaining Evolent's benchmarked Utilization/Cost Management Program and relevant Clinical Quality Improvement Programs.**

**Responsible for a 1/3 management duties and 2/3 operation queue work**

**Other duties as assigned may include but not limited to the following:**

**Supports pre-admission review, utilization management, and concurrent and retrospective review and A & G processes.**

**Participates in risk management, claim adjudication, pharmacy utilization management, catastrophic case review, outreach programs.**

**Participate in the Appeals and Grievance process, as necessary, to assure timely and accurate responses to members.**

**Supports design and implementation of health plan medical policies, and appropriate Care Management and UM goals and objectives.**

**Promotion of managed care systems using evidence-based medicine to educate and facilitate best practices with care management staff and medical providers.**

**Participate in committees as assigned**

**Key Measures of Success:**

**Quality audit results from accrediting and regulatory bodies - 3 year or minimal findings, lack of ICARs or CARs**

**Quality audits for the physicians are meeting or exceeding 95%**

**Inter-rater Reliability (IRR) audits for physicians are meeting or exceeding 95%**

**Year to year percentage of non-unique/unique reviews coming through medical directors**

**Client satisfaction scores**

**The Experience You'll Need (Required):**

**Graduate of an accredited medical school. M. D. Degree is required. Active physician license without any restrictions.**

**3-5 years of clinical practice in a primary care setting and progressively responsible medical administrative experience preferred.**

**2-3 years of direct operating experience in payor-based Utilization and/or Case Management.**

**Finishing Touches (Preferred):**

**Proven ability in medical leadership position possessing clinical credibility with peers and the ability to be a team player and team builder.**

**A thorough understanding of all aspects of managed care, including HMOs, PHOs, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, pharmacy management, and patient centered medical home concepts.**

**Direct experience in NCQA accreditation and auditing of health plans.**

**Excellent interpersonal, verbal, and written communication skills.**

**Consistently completes continuing education activities relevant to practice area and needed to maintain licensure.**

**Ability to navigate in a corporate matrix environment.**

**Technical Requirements:**

Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Evolent Health is committed to the safety and wellbeing of all its employees, partners and patients and complies with all applicable local, state, and federal law regarding COVID health and vaccination requirements. Evolent expects all employees to also comply. We currently require all employees who may voluntarily return to our Evolent offices to be vaccinated and invite all employees regardless of vaccination status to remain working from home. Certain jobs require face-to-face interaction with our providers and patients in client facilities or homes. Employees working in such roles will be required to meet our vaccine requirements without exception or exemption.

**Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.**

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