Job: MED DIR- HEALTHCARE COST MGMT

MED DIR- HEALTHCARE COST MGMT

Requisition Number: 27652

Location: NM - Albuquerque

Type of Opportunity: Regular Full-Time

FLSA Classification: EXEMPT

Minimum Experience: 8 years

Minimum Education: MD

Shift: Days

HCCM (Healthcare Cost Management)

* Provides leadership for the Presbyterian Health Plan (PHP) Healthcare Cost Management (HCCM) Program. Primary responsibility for and direction of PHP healthcare cost management activities including direction and support for Health Services functions: nurses in prior authorization, concurrent and retrospective review, referral coordination, and case management activities.

* Serves as a healthcare cost management resource to all administrative staff of PHP, all PHP product line directors, PHP Health Services, participating providers, and the Presbyterian Medical Group. Provide leadership in the education of members, providers, and PHS entities in the principles of healthcare cost management, particularly as this relates to PHP. Serves as a resource to all customers in regards to national managed care trends, including new methods of management of populations, healthcare costs, and of benefit design.

* Responsible for chairing and having direct oversight of the Healthcare Utilization and Expense Team (HCUET). This includes effective liaison with other PHP departments that collaborate in the PHP or PHS HCCM programs.

* Assists in the development of strategic plans for addressing HCCM concerns and opportunities. Responsible for recording/communicating progress toward meeting any outlined strategic objectives and/or goals.



* Ensures continuous familiarity with PHP primary care, specialist, inpatient, alternative care, and ancillary provider utilization patterns and costs. Assists in identifying and addressing utilization problems, and guiding staff to effective resolution through use of the CQI process.

* Supports PHP referral, authorization, and concurrent review systems, and directly interfaces with providers as necessary to ensure cost-effective care. Works directly with the Director of Health Services to ensure efficiency in Health Services processes related to healthcare cost management.

* Supports Capitated Groups in HCCM strategy. In particular, serves as the primary liaison to PMG with regard to HCCM principles and strategies.

* Liaison with external customers relative to HCCM programs and performance. Includes serving as a resource to internal personnel and creating and presenting information on HCCM to employers, brokers, governmental purchasers, and consumer advisory boards.


Quality Management, Clinical Quality Committee

* Participates in ongoing identification, design, and development of clinical practice guidelines/disease management programs, prevention and wellness initiatives, clinical Quality Improvement Activities (QIA's) incorporating both national standards and local physician input. Serves on PMG UR/QA Committee to assist in development of clinical practice guidelines.

* Chairs and provides clinical leadership to the PHP Clinical Quality Committee.

* Participates in development and implementation of an outcomes-oriented PHP Quality Management Program.

* Available as a resource for the system-wide steps leading up to the attainment of the Malcolm Baldrige award.

* Provides initial Medical Director review of all quality of care complaints and participates in any process improvement initiatives that involve this function.


Pharmacy Benefit Administration and Management

* Serves as the primary Medical Director resource to Pharmacy department personnel in the design, implementation, and continuous improvement of PHP's pharmacy management program, including formulary development and maintenance.

* Serves on the PHP Pharmacy and Therapeutics Committee and participates as an advisor in all pre-meeting planning with department staff.

* Directly responsible for completing all Medical Necessity determinations in the Pharmacy prior authorization process. Serves as an advisor to department staff in any process improvement initiatives that involve this function.


Benefit Development and Interpretation

* Serves as the Chairperson of the Benefit Development and Interpretation Committee (BDIC) to develop and approve Plan policies and implementation plans regarding benefit development and interpretation. This includes responsibility for the maintenance of the Benefit Interpretation Manual.

* Participates in all strategic planning that relates to benefit and product design in the Medicare + Choice and Commercial/ASO areas.



Additional Key Functions

* Works jointly with the Chief Medical Officer to review all Medical Directors' roles and functions to ensur

M.D. or D.O. degree, with board certification at some time. Five years clinical practice experience currently licensed to practice without restriction. At least three years experience in a managed care setting. Experience crafting, implementing, monitoring, and championing clinical practice guidelines and resource, utilization, and cost management initiatives. Coursework or formal training in business desirable (e.g. M.B.A. or M.P.H. degree, courses sponsored by ACPE, Presbyterian Executive Leadership Program at RO Anderson School).
Requires detailed knowledge of utilization management principles, including case management, retrospective and concurrent review, and prior authorization, in terms of theories and practices to serve as the resource or educator to other practitioners. Sound understanding of managed care environment, including various financing mechanisms (e.g., capitation). Familiarity with National Committee for Quality Assurance (NCQA) and with Health Plan Employer Data and Information Set (HEDIS) principles and requirements.