Senior Medical Director for Affordability & Medical Cost Optimization

Senior Medical Director for Affordability & Medical Cost Optimization

Requirements

• Requires an MD or DO with a current unrestricted license to practice medicine.
• Requires American Board of Medical Specialties (ABMS) board certification.
• Requires a minimum 5 years of clinical practice experience.
• Requires a minimum of 3 years of experience in managed care/medical management.
• Requires proficiency working with a Windows based environment including MS Office products.

Responsibilities

• Define a multi-year Medical Cost Optimization (MCO) strategy to drive affordability based on Horizon BCBSNJ experience, external data, competitive intelligence and implement this strategic vision, in collaboration with the MCO Strategy Lead.
• Partner with leadership across Horizon BCBSNJ business units to identify MCO opportunities and drive progress toward operational process improvements to ensure continual, measurable improvement of the quality, compliance, and speed of execution of MCO initiatives.
• Work collaboratively with the Clinical Analytics, Medical Economics, Finance, and other teams to source and validate the sizing and clinical efficacy of MCO business cases.
• Oversee tracking, analysis and reporting of data related to MCO to support the building of business cases, ROI analyses and measurement of progress toward MCO goals.
• Direct MCO work to guide opportunity and solution evaluation and prioritization using the principles of the MCO Committee governing framework to ensure achievement of multi-year affordability, quality, and clinical outcome targets.
• Facilitation of, and participation in, MCO Committee meetings.
• Facilitate prioritization of MCO solutions in need of funding through the CPLT and DRIVE processes.
• Partner with the Medical Cost Action Planning (MCAP), Finance and Actuary teams on tracking and reporting of enterprise MCO and MCAP performance.
• Communicate MCO strategy, activity and results across HNS and the enterprise.
• Communicate MCO efforts externally to network providers and their respective trade organizations.
• Educate Horizon BCBSNJ staff on MCO tools, strategies, and programs.

Preferred Qualifications

• Active, unrestricted MD or DO license required, NJ license preferred.
• No CMS sanctions or sanctions by other regulatory agencies or boards.
• Must be board certified by a specialty recognized by the American Osteopathic Association or the American Board of Medical Specialties.