AVP, Medicare Medical Services

AVP, Medicare Medical Services

Reporting to the CMO of Government Products, the AVP, Medicare Medical Services serves as one of the strategic and tactical leaders who works with providers and stakeholders to develop and execute on our population health strategy, clinical and provider operations, and State contract and CMS requirements for the Government products, with a focus on Medicare, including Special Needs Products for UPMC Health Plans. The AVP works closely with the President of Medicare product and Population Health functional business units to improve plan performance with the goal to realize the Quadruple Aim of better health, better care, lower costs, and higher clinician satisfaction. The role is primarily working with health plan Medicare (including Special Needs Plans) products business teams, Population Health teams, delivery system, and community leaders. This leader also promotes affordability and cost-effective practice patterns through appropriate interventions with healthcare providers and health plan programs. She/he will be directly involved in interactions with physicians, hospitals, provider practices and related networks, directing and responding to performance management, and monitoring and implementing programs to improve the quality and affordability of medical services.

Responsibilities include:

• Co-leading performance improvement efforts for management of Medicare SNP (and related product) to include leading, educating and mentoring the clinical team and providing product specific guidance to Quality, Utilization and Care Management, and Population Health.
• Participating in the creation of opportunities to consult, interact, and elicit feedback with the physician and provider community.
• Developing strategies enhancing proactive clinical interventions and serving in the design and implementation of medical management initiatives to improve the quality and cost effectiveness of care delivered.
• Offering clinical insights to population health performance (quality, utilization and cost) trends, utilizing member and scientific data for continual improvements.
• Collaborating with key UPMC health plan and delivery system leaders on clinical and performance improvement strategies and tactics specific to our parent health system, largest provider, and integrated delivery and financial system partner.
• Providing clinical support for the Quality Improvement program, including study design for NCQA accreditation initiatives, coordination of measures reporting, as well as meeting or exceeding all regulatory requirements.
• Serving as a 'role model' and 'health advocate' within the Pennsylvania community, including active participation with UPMC sponsored activities, public events and community outreach programs.
• Creating and managing performance improvement programs to improve the UPMC Network's quality and efficiency performance.
• Working collaboratively with UPMC Data Analytics team to develop/improve standard performance reporting and further understand performance and opportunities for improvement.
• Influencing medical cost trend in partnership with network services and medical management teams including development of trend-specific initiatives and identification of medical management best practices.
• Actively participating in the utilization management and quality improvement review processes.
• Participating in activities to support policy decision making.
• Developing informational tools and materials that support clinical quality and efficiency initiatives.
• Monitoring network and group performance and meeting regularly with key provider group Medical Directors, Administrators, and other team members to drive mutually acceptable performance goals.
• Actively interfacing with hospitals, SNFs and other care partners to improve care outcomes, utilization and cost.
• Providing support and coverage for the CMO and other Medical Directors when needed.

PA medical license required. Minimum of 2 days per week onsite in Downtown Pittsburgh and willingness to travel throughout PA. Master's degree in business or health related field preferred. Direct experience with managed care organizations is preferred. Senior level management experience with at least 5 years of experience in health care delivery systems management in a managed care environment. Strong QI and Utilization background with a working knowledge of finance, management information systems, and statistical analysis. Knowledge and experience with regulatory requirements for delivery of health plan products including government products and specifically Medicare and SNPs. Competency in interpersonal skills and analytical, communication, and problem-solving skills, clinical proficiency, team and customer service orientation, and the ability to deal with ambiguity and out of the box thinking. Must possess experience with academic and community-based providers. Must maintain clinical specialty board certification and state licensure. May be required to add additional state licensure to support responsibilities. Nurture personal and professional growth/development and establishing professional affiliations to keep abreast of latest trends in field of expertise. Mentorship commitment from Chief Medical Officers and senior leaders.

Doctor of Medicine (MD or DO) with an active State license and Board certification. UPMC is an Equal Opportunity Employer/Disability/Veteran.