Job Description
Reporting to the Community Health Choices Market Chief Medical Officer, the CHC LTSS Medical Director provides medical leadership in the areas of LTSS utilization management and quality management to advance business objectives and improve the health and safety of our participant population. Work Arrangement: Fully Remote 20 hours per week The CHC LTSS Medical Director will be responsible for: Performing medical reviews of Service Coordination/UM case rounds cases for personal assistance service requests. This may include communication/discussion with the UM reviewers and service coordinators as needed. This may include identification of trends, process improvements and educational needs for the service coordination and/or LTSS Utilization Management teams. Performing review of clinical quality-of-care cases. This may include discussion with quality clinical reviewers and review of provider CAPs, CAP responses and drafted letters. This may also include identification of quality trends and process improvements. Performing review of residential habilitation requests for participants with brain injuries. This may include communication/discussion with the UM reviewers and service coordinators as needed. This may include identification of trends, process improvements and educational needs for the service coordination and/or ltss um teams. Performing review of out of network physical health UM cases. This may include discussion with physical health UM medical directors, identification of trends and process improvements Accountabilities: Renders decisions and supports processes that are participant-centered, and aligned with Plan objectives, addressing clinical and non-clinical needs and health equity in all functions. Engenders trust. Supports the CHC CMO needs and delivers timely, complete assignments as directed. Tracks and meets key performance indicators. Provides leadership and interventions to ensure appropriate, cost-effective, efficient care. Supports and upholds regulatory requirements, compliance, policies and contractual agreements, and mitigates risk. Knowledgeable on policies, contracts, government mandates or other requirements with clinical, operational, and financial impact. Thoroughly documents all case review activity in the participant record in the appropriate electronic case management documentation systems. Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures and supports and carries out the ACFC mission and values. Other duties as assigned. Requirements: Leadership experience in Medicaid managed care/health plan (preferred) or large health care organization with direct experience in Medicaid CM, quality performance and utilization management. Experience with LTSS preferred. Full time experience practicing clinical medicine. Experience with older adults and individuals with disabilities preferred. License Requirement: Must be licensed to practice medicine in the state of Pennsylvania Must be Board-certified in his/her medical specialty. Preferred specialties: Geriatrics, Physical Medicine and Rehabilitation, Neurology Must be clear of any sanctions by the applicable state or Office of the Inspector General Must not be prohibited from participating in any Federal or State funded healthcare programs. Other Skills: Strong written and oral communication skills required Demonstrated competency in use of healthcare data. Demonstrated excellent interpersonal communication skills and presentation skills. Experienced in conflict resolution and negotiation. Understanding of and expertise in quality improvement and medical economics. Strong leadership skills. Excellent analytical and problem-solving skills. Demonstrated ability to access department’s work quality and develop / implement process improvements to achieve regulatory and oversight compliance. Maintain current knowledge of and applies all applicable licensing, regulatory and industry standards Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more. Your career starts now. We are looking for the next generation of health care leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of