CMO- Virginia - LTSS Programs
Clinical Services is focused on driving measurable and meaningful improvement in the use of evidence-based medicine, patient safety, practice variation and affordability. In serving our Medicare, Medicaid, and commercial members & plan sponsors, our Clinical Services teams partner with our network of physicians, hospitals and other health care professionals to achieve these goals. We are committed to our mission of helping people live healthier lives.
Reporting to the Executive Director for the Community and State Long Term Services and Support plan of Virginia.
- Supports a fully integrated clinical model of care, in collaboration with Behavioral Health and other clinical management
- Responsible for appropriate utilization management including managing/monitoring the results of Care Management/ Health services interventions to ensure that utilization goals are achieved; collaborating with Care Management/ health services/behavioral health and members/caregivers as necessary to maintain focus on achieving targets
- Performs daily review of personal care attendant services to approve or deny appropriate services for members
- Will work with care coordination staff to clarify requests and documentation as needed
- Supports all clinical quality initiatives and peer review processes
- Participates in healthcare affordability initiatives and meetings at the local market
- Conducts provider telephonic review and discussion, schedules on-site visits and shares tools, information and guidelines related to cost-effective health care delivery and quality of care as necessary
- Effectively engages and brings understanding to our external constituents such as physicians, medical and specialty societies, hospitals and hospital associations, and state regulators
- Participates in the HEDIS data collection process, CAHPS (Consumer Assessment of Healthcare Providers and Systems) improvement, and drive Health Plan accreditation activities
- Provides support for all external audits by state and other regulatory agencies
- Responsible for identifying opportunities through participation in local medical expense committees or market reviews
- Collaborates with the health plan Health Services Director and other clinical staff as a clinical resource and coach to establish and implement programs to support and meet the UM and member goals
- Collaborates with the Health Services Director, clinical operations staff and other market staff to implement programs to support and meet market and national clinical operations goals
- Accountable for providing clinical leadership primarily focusing on home and community based services review and external communication with network physicians
- May assist in the development and implementation of local plan clinical policies and procedures, quality improvement activities and performance improvement projects
- MD or DO with an active, unrestricted Virginia license
- Board Certified in an ABMS or AOBMS specialty
- 5+ years clinical practice experience, preferably in geriatric medicine
- Intermediate or higher level of proficiency with managed care
- 2+ years Quality Management experience
Careers at UnitedHealthcare Community & State. Challenge brings out the best in us. It also attracts the best. That's why you'll find some of the most amazingly talented people in health care here. We serve the health care needs of low income adults and children with debilitating illnesses such as cardiovascular disease, diabetes, HIV/AIDS and high-risk pregnancy. Our holistic, outcomes-based approach considers social, behavioral, economic, physical and environmental factors. Join us. Work with proactive health care, community and government partners to heal health care and create positive change for those who need it most. This is the place to do your life's best work.(sm)
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Sorry,this is NOT an opportunity for Search Firm recruiters.