Chief Medical Officer, Utilization Management

Key responsibilities:

Transitional Care Management (TCM) Program:
- Readmission reduction
- Appropriate LOS
- Member engagement
Implement “Shadow UM rounds” w/Plan partners (level of care review and enhanced discharge planning)
- Inpatient
- SNF
Embed clinical criteria (MCG) into TCM/Medical Director workflows
- Laying framework for possible future UM delegation
Medical Director integration w/TCMs rounding in hospital/SNF
- Clinical case reviews, fidelity of model, hospital relationship building
- Post-Acute Pathway
- SNF bed day management
Community based provider post-hospital integration
Complex Care Management program
Relationship/partnership building: Health Plan UM team, Hospitals/Facilities, Community Provider Groups, Home Health Agencies
Other affordability interventions: Clinical pathways, ASC, Internal Prior-auth, Referral management
Hands on, individually and working with others developing program materials, helping train and implement/operationalize, meeting with market leadership, attending TCM/UM rounds, relationship building/nurturing…

Senior Medical Director, Utilization Management is responsible for leading, developing, and implementing clinical interventions and population health management programs that appropriately reduce utilization, improve quality, and promote affordability to meet AbsoluteCare’s risk bearing, value-based program cost savings goals. This also includes working closely with AbsoluteCare’s medical director team to continue to improve the transitional care management and post-acute interventions and workflows – this includes rounding with the TCM team in the hospital, incorporating level of care clinical criteria (i.e. MCG – Milliman Care Guidelines)), hospital relationships, and health plan UM partnerships.

This role will work alongside the Chief Medical Officer, Complex Care and in conjunction with other AbsoluteCare multidisciplinary leaders to promote interdisciplinary care coordination and drive clinical affordability programs. The Senior Medical Director, Utilization Management will be a champion for AbsoluteCare member and employee engagement.

Develop and implement best in market community-based clinical affordability programs.
Improve and continue the development of best-in-class transitional care management and post-acute programs. Incorporate level of care clinical criteria to help drive clinical and bed day decisions. This includes working closely with our medical directors, hospitals, SNFs and health plan partners.
Focus on programs that advance our model of care serving high risk, high cost, vulnerable populations and control total cost of care. With attention to:
- Market leading access to care and interventions
- Member engagement and satisfaction
- Reduction of admissions, readmissions, ED visits and skilled nursing facility days
- Improved HEDIS and Stars measures
Responsible for affordability initiatives and associated budgeted outcomes.
Provide strategy and content for population health and affordability reporting with the ability to interpret that leads to action: successful clinical program development and continuous process improvement leveraging data.
Collaborate and help lead with providers, care management, behavioral health, transitional care, center based shared services and other AbsoluteCare multidisciplinary leadership to ensure efficient communication and coordination of care. Policies and workflows are clearly documented and implemented.
Develop community care management programs that integrate well with and assist non-community providers and facilities to improve outcomes for shared populations.
Help oversee programs and strategy for non-AbsoluteCare community providers to improve provider engagement.
Develop other affordability programs to appropriately reduce total cost of care.
Provide leadership, vision and positive culture for our clinical teams.

In-depth knowledge of Medicaid, Dual, and Medicare programs – including associated products, trends, competitive programs and a deep understanding of how innovative value based clinical programs can improve the total cost of care.
Strong experience and demonstrated success leading full risk, risk bearing value-based clinical programs, total cost of care, and/or Accountable Care Organizations.
Demonstrated understanding of Utilization Management, level of care review, and bed day management. Milliman Clinical Guidelines (MCG).
- Health plan experience a significant plus
Experience and demonstrated success developing, implementing, and managing transitional care, post-acute, and community-based clinical delivery models.
Proven ability to lead and execute within a matrixed management structure.
Skillful with change management and mentoring providers regarding at risk value-based care
MD/DO with certification by an American Board of Medical Specialties (ABMS) in Internal Medicine, Emergency Medicine, Family Medicine or similar relevant specialty.
- Special focus - experience with:
  - Hospitalist/Inpatient and/or Emergency Department experience or,
  - hospital-based Physician Advisor