About the job
PURPOSE OF THE POSITION:
Assures the competence and soundness of Affinity’s service delivery program by providing professional expertise (i.e., guidance, advice, decisions, actions and judgments) to all areas of the organization including, but not limited to, Care Delivery operations, regulatory affairs, corporate compliance and quality improvement. This position also assists the Chief Medical Officer in articulating Affinity’s health care vision and medical management model, and in establishing clinical policies, practices, standards and programs that are a) coherent and internally consistent, b) comply with relevant laws, rules, regulations and professional standards, and c) contribute to achievement of corporate strategies, goals and objectives, and fulfillment of the corporate mission and vision.
1. Provides professional expertise and services that support the Care Delivery Division, including, but not limited to, the following.
a) Utilization management:
- implements clinical guidelines and supports UM staff use of guidelines, protocols and criteria in conducting utilization review and case management activities;
- assures that corporate utilization policies comply with State and industry standards;
- works with the UM Director to analyze trends in service utilization, and develop and implement innovative care, case and disease management programs based on findings;
- performs daily prior authorization, concurrent and retrospective case reviews; and
- assists in oversight of delegated UM arrangements.
- conducts the peer review component of corporate credentialing activities, assuring that credentialing decisions are supported by available utilization and quality of care information;
- assures that credentialing policies, standards and procedures are consistent with State and industry requirement and standards;
- confers with participating providers regarding clinical and quality data used in credentialing decisions.
c) Provider network:
- works with other departments to assess network adequacy, and develop appropriate strategies to expand and strengthen provider network capabilities;
- interacts and communicates directly with providers regarding network participation, access, availability, quality improvement and related clinical and service delivery issues; and
- collaborates on strategies to assure that Affinity is the “health plan of choice” for providers.
d) Quality management and related initiatives:
- conducts inter-departmental rounds to promote effective, efficient, high quality care management, and contribute to staff education and development;
- staffs the Credentialing, Pharmacy and Therapeutics, and Medical Peer Review sub-committees, including development and direction of specialty peer review panels;
- analyzes clinical and quality data to identify areas for performance improvement;
- works with inter-departmental staff, network clinicians, state and local health departments and industry colleagues to plan, implement and evaluate new programs, community outreach strategies, and clinical quality improvement activities; and
- participates in developing quality of care studies, and works with network clinicians to pursue subsequent quality improvement efforts.
2. Provides professional advice, guidance and support to other operational, analytical and strategic activities of the company, including, but not limited to, marketing, member services, claims, and public affairs.
3. Represents Affinity on appropriate local, State, and national trade groups, governmental and industry workgroups and committees and similar external venues; seeks opportunities to report on Affinity’s projects and programs.
4. Develops and maintains positive, constructive, mutually beneficial relationships that promote Affinity’s goal of being the “health plan of choice” for providers, consumers and purchasers.
1. License to practice medicine in New York State.
2. Board Certification in a primary care specialty.
3. Minimum of three(3) years of experience as an associate medical director or medical director working with utilization management, peer review, network assessment and provider relations, and quality improvement, preferably in an HMO environment. Working knowledge of clinical protocols, utilization review standards, and professional credentialing standards, policies and procedures.
4. Minimum of five (5) years of clinical practice experience, preferably serving an urban population.
5. General and managed care business knowledge demonstrated by:
- comprehensive knowledge of managed care principles, structure and care delivery arrangements, including principles of UM, QM, credentialing, clinical criteria and guidelines, and the resources (such as information systems) that support effective functioning;
- knowledge of relevant managed care laws, rules and regulations;
- familiarity with the health issues, health care delivery system, and key government and professional constituencies in Affinity’s service area; and
- working knowledge of managed care finance and business operations.
6. Management, consultative and process skills required to initiate, implement and complete tasks and responsibilities in a timely manner, and to promote coordination of activities across departments or divisions.
7. Highly developed interpersonal and management skills, characterized by the ability to persuade, listen, interpret, negotiate, mediate, mentor, teach, consult and advise inside and outside of the organization, and to manage critical internal and external relationships.
8. Good judgment in a) seeking and using information to support decision making, b) anticipating the consequences of decisions and actions, c) communicating information, d) interacting constructively with others inside and outside the organization, e) maintaining confidentiality as appropriate, and f) choosing actions that are beneficial to, and consistent with the mission, goals, culture and style of the organization.
9. Ability to consult, advise and influence others in the absence of formal authority or direct reporting relationships.
10. Organizational skills demonstrated by the ability to anticipate needs, to prepare appropriately and to organize and complete work efficiently and effectively.
11. Strong analytical skills, demonstrated by ability to identify and use qualitative and quantitative clinical and operational information and data to identify needs, select among competing approaches, make decisions, set priorities and monitor progress towards goals and objectives and desired outcomes.
12. Excellent writing and verbal communication skills characterized by the ability to articulate complex concepts and quantitative and qualitative information to diverse audiences.
13. Enthusiastic understanding and commitment to the corporate mission, vision, and values; understanding of, and sensitivity to, the needs, behaviors and expectations of a culturally diverse Member and provider population.
15. Demonstrated integrity, trustworthiness, respect for others, and ability to deal appropriately with confidential and sensitive information.
- Health Care Provider
- Total Years Experience 0-5
- Remote Work No remote work