Senior Medical Director - FIDE IL

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

This is a full-time, remote role. The ideal candidate will live in the state of IL.

• Responsible for clinical oversight of DSNP/FIDE complex populations (Duals Special Needs)
• Develop and lead clinical strategy and objectives for the DSNP/FIDE populations, including the development and implementation of clinical initiatives and programs to address the needs of the populations managed to improve health outcomes.
• Leverage extensive knowledge of health care delivery system, utilization management, reimbursement methods and treatment protocols for DSNP/FIDE and other complex health populations to optimize risk adjustment, clinical quality, and care management.
• Actively participate in meetings and communication with the State Department of Medicaid in person as needed.

• Outward facing position to interact and collaborate with medical / physical professional associates, the local provider community, state regulatory agencies and advocacy groups to advance clinical excellence and the delivery of cost-efficient care. Will also Interact with the members, health systems, nursing facilities, as well as home and community-based networks. Make face to face visits with medical / physical professional associates, the local provider community, state regulatory agencies and advocacy groups for discussions for trend discussions. Attend In person provider and Member meetings as needed.

• Develop and guide the implementation of medical management programs to ensure providers deliver appropriate, high-quality, cost-effective health risk assessments and other clinical services that are evidence-based.
• Work collaboratively with the Behavioral Health, Pharmacy, member outreach, Care Management, National Quality Management, Utilization Management, Compliance, and other departments to integrate social, behavioral, and physical health and improve clinical program execution.

• In collaboration with health care analytics teams, develop analytical models, interpret results, and extract insights on the clinical drivers and trends and tracks data to improve the delivery of population health care to create value for members, providers, and the health plan. Understand trend and create solutions. Good with data interpretation. 
• Be able to effectively communicate these finding to Senior Management and staff at all levels.
• Develop and deliver conference presentations or other presentations (written or oral) that support the health plan in a professional and effective manner.

• Actively participate in State Fair Hearings as needed or any State calls.   Understand UM and participate in UM front line work and appeals in markets as needed.
• Confer directly with providers regarding the care of patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions.
• Work with medical director teams focusing on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review, and provider appeals clinical review.

• Actively participate in scheduled team meetings and leadership meetings, at the health plan, local, state, regional, or national levels.
• Facilitate interdisciplinary care team rounds for DSNP/FIDE members.
• Develop effective working relationships with internal clinical team, facilitate educational and coaching opportunities for the internal clinical team, as well as establish relationships and/or consult with external agencies. Must be willing to cross cover for other colleagues and become mentor for other MDs as needed and be on call as needed.

• Partner with appropriate entities in the investigation of potential quality of care concerns and/or grievances.
• Actively support compliance functions to maintain standardized systems, policies, programs, procedures, and workflows that ensure the health plan exceeds care management, regulatory, and quality standards.
• Support the activities of other plan leadership as required or assigned.
• Be an active voice and participate in all internal and external committee meetings. 
• Actively participate in quality improvement activities internal and external to the organization with multiple stakeholders.

• Help achieve or exceed all applicable HEDIS, Stars and local state performance targets and goals otherwise specified for the plan. Be present for regulatory audits in person. 
• Support all Clinical Quality initiatives and peer review processes including Quality of Care and Quality of Service (grievance) issues.
• Actively participate in or lead quality and/or member/provider service-focused committees.
• Provide clinical leadership in preparation for program audits and/or certification processes.

The typical pay range for this role is: