Under the administrative direction of the UPMC Insurance Services Division Commercial & Medicare Chief Medical Officer and the Chief Medical Officer, this senior leader will serve as a strategic, collaborative business partner and is responsible for the clinical strategy, operations, and compliance for the commercial products for UPMC Health Plan. This position will also have strategic oversight and responsibility for utilization management of Commercial products and services. This position will oversee the management of Commercial Products physicians, serve as the authority on medical issues and is responsible for compliance with all clinical medical policies, directives, rules, regulations and clinical performance standards of state and federal governments and all accrediting bodies for the Commercial line of business.
This senior leader is accountable for ensuring the membership receives exceptional service and that clinical outcomes meet or exceed all standards or benchmarks. He/she assures best standards of practice and promotes person centered, recovery-focused care models and policies working with internal and external stakeholders to represent an integrated approach to health. This leader also promotes cost-effective practice patterns through appropriate interventions with health care providers while meeting or exceeding the expectations of internal and external customers by utilizing first-hand member and scientific data for continual improvements for products and services. He/she will be directly involved with interaction of physicians, hospitals, physician practices and related networks, directing and responding to risk management issues, monitoring and implementing programs to improve the quality of medical services provided. This key physician leader will be responsible for interaction with UPMC payer/provider clinical leadership (physicians, hospitals, physician practices and related networks) to further insure effective and efficient clinical care of the Commercial membership.
Contribute clinical and operational expertise to Commercial & Medicare CMO and all senior management activities at the Insurance Services Division.
Represent UPMC Health Plan at local, state and national forums as appropriate and directed in the oversight and management of Commercial clinical services.
Oversee member, provider and clinical communication materials and documents for clinical content and program accuracy for the Commercial lines of business (FI, ASO, and ACA products).
Develop and cultivate strong working relationships with regulatory entities.
Participate in the strategic planning of the UPMC Insurance Services Division. Exemplify a collaborative approach to work ethic for staff to model.
Establish and monitor the appropriate budget as assigned.
Work closely with WorkPartners and UEG clinical and administrative leadership in development of cross segment strategies.
Select, retain, develop, and reward a competent staff.
Develop strategies to foster external relationships.
Recommend annual plan along with the strategies, tactics and resources for Commercial Lines of Business necessary to achieve division goals and objectives directly related to the essential functions of the position.
Manage the development, implementation, and provision of ongoing clinical evaluation of the Commercial lines of business as assigned.
Provide leadership in advancing appropriate alternative payment models and other future opportunities.
Oversee the standardization of practice patterns and the achievement of desired outcomes through clinical resource management.
Provide support of the provider relations activity of the lines of business as assigned.
Provide strategic guidance of utilization management and medical policy programs/areas as necessary to support Commercial products.
Provide leadership for continuous NCQA activities to maintain excellent accreditation in Commercial products as appropriate.
Support and guide the Medical Directors in the assigned lines of business in regard to meeting and exceeding standards or benchmarks for quality care and establish benchmarks or standards as needed.
*Performs in accordance with system-wide competencies/behaviors.
*Performs other duties as assigned.
MD license required.
Master's degree in business or health related field preferred.
Senior level manager with at least five 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.
Direct experience with NCQA accreditation for managed care organizations.
Knowledge of an experience with regulatory requirements for the delivery of health plan Commercial products.
Must demonstrate competency in interpersonal skills and political savvy, analytical, communication, and problem-solving skills, clinical proficiency, team and customer service orientation, the ability to deal with ambiguity and "out of the box" thinking.
Must possess the ability to interact on an academic as well as community-based level.
Knowledge and experience with regulatory requirements for delivery of health plan Commercial products.
Licensure, Certifications, and Clearances:
Doctor of Medicine (MD)
UPMC is an Equal Opportunity Employer/Disability/Veteran
Internal Number: 227083131
About UPMC Health Plan
UPMC Health Plan, headquartered in Pittsburgh, Pennsylvania, is among the nation's fastest-growing health plans. It is owned by the University of Pittsburgh Medical Center (UPMC), a world-renowned health care provider. As part of an integrated health care delivery system, UPMC Health Plan is committed to providing its members better health, more financial security, and the peace of mind they deserve. UPMC Health Plan partners with UPMC and community network providers to produce a combination of knowledge and expertise that provides the highest quality care at the most affordable price. The UPMC Insurance Services Division—which includes UPMC Health Plan, Workpartners, UPMC for Life, UPMC for You, UPMC for Kids, UPMC Community HealthChoices, and Community Care Behavioral Health—offers a full range of group health insurance, Medicare, Special Needs, CHIP, Medical Assistance, behavioral health, employee assistance, and workers' compensation products and services to more than 3.9 million members. Our local provider network includes UPMC as well as community providers, totaling more than 140 hospitals and more than 29,000 physicians throughout Pennsylvania and parts of Ohio, West Virginia, and Maryland.