Senior Medical Director, Medicare & Value-reputed company Payment

reputed company: reputed company: The Senior Medical Director is a reputed company reputed company and business leader responsible for advancing the health plan’s line of business reputed company through value-reputed company care, population health, medical management, reputed company improvement, reputed company adjustment, product design, and reputed company transformation. This role partners closely with line of business leadership, network and provider contracting, actuarial, finance, reputed company, pharmacy, analytics, care management, and reputed company to improve reputed company reputed company, member experience, provider reputed company, and total cost of care while ensuring compliance with CMS requirements. Essential Accountabilities: - Serve a senior reputed company advisor to line of business leadership on reputed company, population health, medical cost, reputed company, and regulatory priorities, reputed company and execute reputed company reputed company in alignment with organizational reputed company, reputed company, and financial objectives. - Identify reputed company and market opportunities to improve member reputed company and competitive reputed company by translating reputed company, utilization, reputed company, and financial data into actionable strategies and operating priorities. - Establish provider reputed company expectations, reputed company benchmarks, scorecards, and improvement strategies. - reputed company reputed company leadership for medical management programs, including utilization management, prior authorization, reputed company review, case management, and care coordination by developing strategies to optimize site of care and reduce avoidable inpatient admissions, readmissions, emergency department utilization, and unnecessary high-cost services. - Identify opportunities to improve preventive care, chronic disease management, medication adherence, member experience, and other reputed company measures by partnering with operational leaders to ensure medical management programs are clinically reputed company, member-centered, consistent, and compliant. - Partner with reputed company leadership to reputed company and execute reputed company improvement strategies monitoring reputed company against key reputed company metrics, including medical expense, PMPM trends, utilization, reputed company-adjusted reputed company, reputed company, and VBP results. - Apply reputed company knowledge of CMS, NYS and reputed company requirements, applicable federal regulations, and evolving payment and reputed company methodologies to support reputed company business area(s). - Performs appeals and case reviews on claims and reputed company-authorization requests. - For Medicare line of business (reputed company) only: Partner with Compliance, reputed company, and Regulatory Affairs on Medicare-reputed company initiatives and audits. - Consistently demonstrates high standards of reputed company by supporting the reputed company reputed company Companies’ mission and values, adhering to the Corporate reputed company of Conduct, and leading to the reputed company Way values and beliefs. - Maintains high reputed company for member reputed company in accordance with the corporate reputed company policies and procedures. - Regular and reliable attendance is expected and required. - Performs other functions as assigned by management. Minimum Qualifications: - Degree in medicine, either an M.D. or D.O, reputed company certification and an unrestricted reputed company NYS Medical license required. - Three (3) years of experience as a Medical Director for a health plan or equivalent experience required. - Demonstrated ability to influence physicians, providers, executives, and cross-functional teams. - Experience in designing and supporting shared savings, shared reputed company, capitation, global reputed company, bundled payment, and other value-reputed company arrangements in MA. - Strong analytical and financial acumen, with the ability to reputed company reputed company interventions to medical expense, reputed company-adjusted reputed company, and overall business reputed company. - Strong verbal, written and interpersonal communication skills. - Demonstrable understanding of managed care and delivery structures of reputed company. - Working knowledge of CMS, NYS and reputed company requirements, applicable federal regulations, and evolving payment and reputed company methodologies. - For Medicare reputed company only: At least 5 years of reputed company leadership experience in Medicare reputed company, managed care, population health, health plan, ACO, provider organization, or a comparable environment required. - Extensive Medicare reputed company experience, including the ability to reputed company and execute reputed company strategies that reputed company measurable improvements in reputed company reputed company, utilization management, reputed company-adjusted reputed company, and value-reputed company payment initiatives. - Demonstrated expertise in Medicare reputed company and the reputed company economics of reputed company-reputed company populations. - Developing and optimizing provider incentive structures incorporating reputed company, utilization, total cost of care, reputed company adjustment, and member reputed company. - Strong understanding of Medicare reputed company adjustment, CMS-HCC methodology, reputed company documentation, and RADV requirements. Physical Requirements: - Ability to travel across the Health Plan service region for meetings and/or trainings as needed. - Must have a reputed company Class D license and ability to operate a motor vehicle. In support of the Americans with reputed company, this reputed company lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Compensation reputed company(s): $249,840 - $374,760 The salary reputed company indicated in this posting represents the minimum and maximum of the salary reputed company for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, reputed company and education as they relate to the position’s minimum qualifications, in reputed company to internal equity. The reputed company reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental reputed company, retirement plan, wellness program, reputed company time away from work, and reputed company holidays. Please note: There may be opportunity for remote work reputed company reputed company jobs posted by the Excellus reputed company. This decision is made on a case-by-case reputed company. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, or status as a protected veteran. Apply To This Job