Clinical Operations & Physicians
Senior Medical Director
Albuquerque, NM, United States

It’s Time for a Change …

 Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way healthcare is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard, and Evolenteers often make a difference in everything from scrubs to jeans.

 Are we growing? Absolutely—56.7% in year-over-year revenue growth in 2016. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

Who You’ll Be Working With:

You will be working at True Health New Mexico in the Medical Management department, reporting to the Chief Medical Officer (CMO), and providing leadership across all Medical Management areas. You will also work closely with the Director of Pharmacy; the Senior Director of Clinical Quality and Medical Management; and the Case Management, Disease Management, and Utilization Management departments. 

What You’ll Be Doing:

The Senior Medical Director drives programmatic to member care in the areas of utilization and quality. This includes the development and monitoring of innovative provider payment approaches, including Patient Centered Medical Home (PCMH), bundled payments, shared savings, partial capitation, and full capitation throughout the Company’s provider network. The Senior Medical Director also:

  • Assists in full range of Medical Director activities, including utilization reviews, quality reviews, grievances and appeals, and credentialing.
  • Chairs the Integrated Clinical Management Committee with oversight of Disease Management, Utilization Management, Behavioral Health, Community Health, and Complex Care Management activities in conjunction with the Chief Medical Officer, Senior Director of Quality and Medical Management, Behavioral Health Director, Pharmacy Director. and third-party vendor(s).
  • Participates in the Evolent Pharmacy and Therapeutics Committee and the Evolent Medical Policy Committee.
  • Supervises the Company’s Medical Directors and the Director of Community Health.
  • Performs initial determinations and appeal decisions, including peer-to-peer discussions to support network providers’ broader care planning efforts.
  • Supports ongoing activities for National Committee for Quality Assurance (NCQA) accreditation in collaboration with the Senior Director of Quality and Medical Management.
  • Oversees the Utilization Management activities related to NCQA accreditation and Office of the Superintendent of Insurance regulation, including policy and procedure development and review, monitoring UM service level agreements, monitoring UM metrics, and implementing programmatic changes as required.
  • Oversees the programmatic development and integration of community health worker and population health strategies.
  • Supports third-party vendor activities to meet service level agreements for the Company’s Member Service Agreement client, including participation in the Joint Operating Committee, developing action plans when service level agreements not met and when medical trends are not at goal.
  • Supports Medical Management activities related to the Company’s expansion into additional lines of business.
  • Collaborates and supports Product Development and Benefit Design to ensure delivery of services to insured members consistent with the mission and vision.
  • Supports the implementation and ongoing activities for the risk adjustment program related to member risk identification and stratification.
  • Supports the evaluation of new technologies in consideration of service coverage expansion.
  • Evaluates new health IT-related solutions in support of enhanced member and provider engagement.
  • Supports provider network optimization and contracting efforts, including the fostering of collaborative relationships with lead physicians.
  • Provides on-site leadership for design, implementation, and continuous improvement of value-based, innovative payment strategies across the provider network, including PCMH, bundled payments, shared savings, partial capitation and full capitation.
  • Works closely with practices participating in value-based payment to review performance and revise utilization and quality goals based on industry standards and evidence-based literature, in conjunction with the Company’s evolving goals.
  • Participates in Behavioral Healthcare Management related to PCMH activities.
  • Remains current with published materials, such as federal or state regulatory decisions, particularly those that may impact PCMH programs and NCQA accreditation.
  • Participates in internal and external presentations, collaborative initiatives and projects, representing the Company’s medical management activities to outside agencies, professional societies, small and large businesses, brokers, and other interested parties.
  • Other duties as assigned.

 The Experience You’ll Need (Required):

  • Current, unrestricted medical license in the State of New Mexico.
  • Board certification.
  • Five years or more of physician leadership experience in health insurance organizations and/or healthcare delivery systems.
  • Ability to create a programmatic vision and to drive development and implementation of the project plan to meet timelines and performance goals.
  • Ability to work collaboratively with a wide range of stakeholders in a variety of settings.
  • Minimum of five years of clinical medical practice.
  • Ability to travel within New Mexico as needed.

Finishing Touches (Preferred):

  • Experience with implementing and/or practicing within a PCMH setting or value-based arrangement such as an Accountable Care Organization.
  • Advanced degree (e.g., MBA, MHA, MPH).

Evolent Health is an equal-opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

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