Medical Director - DSNP/MMP at CVS Health

Florida City, Florida, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Medicare, MedicaidIndustries

Requirements

Extensive knowledge of health care delivery system, utilization management, reimbursement methods, and treatment protocols for DSNP/MMP and other complex health populations
Ability to leverage data interpretation skills to develop analytical models, interpret results, extract insights on clinical drivers and trends, and track data to improve population health care
Strong communication skills to effectively communicate findings to Senior Management and staff at all levels, and to develop and deliver conference presentations or other presentations (written or oral)
Willingness to actively participate in in-person meetings, face-to-face visits, State Fair Hearings, state calls, provider and member meetings, team meetings, leadership meetings, and Interdisciplinary Care Team rounds at health plan, local, state, regional, or national levels
Ability to travel for in-person interactions with State Department of Medicaid, medical/physical professional associates, local provider community, state regulatory agencies, advocacy groups, members, health systems, nursing facilities, and home/community-based networks
Understanding of UM (Utilization Management) and ability to participate in UM front line work and appeals
Ability to confer directly with providers on care for patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions
Willingness to cross-cover for medical director teams focusing on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review, and provider appeals clinical review

Responsibilities

Provide clinical oversight of DSNP/MMP complex populations (Dual-Eligible Special Needs Plan / Medicare-Medicaid Plan)
Develop and lead clinical strategy and objectives for DSNP/FIDE populations, including development and implementation of clinical initiatives and programs to improve health outcomes
Optimize risk adjustment, clinical quality, and care management using knowledge of health care delivery, utilization management, reimbursement, and protocols
Actively participate in meetings and communication with the State Department of Medicaid in person as needed
Interact and collaborate with medical/physical professional associates, local provider community, state regulatory agencies, advocacy groups, members, health systems, nursing facilities, and home/community-based networks to advance clinical excellence and cost-efficient care; conduct face-to-face visits and attend in-person meetings
Develop and guide implementation of Medical Management programs to ensure providers deliver appropriate, high-quality, cost-effective, evidence-based Health Risk Assessments and clinical services
Collaborate with Behavioral Health, Pharmacy, Member Outreach, Care Management, National Quality Management, Utilization Management, Compliance, and other departments to integrate social, behavioral, and physical health and improve clinical program execution
Work with health care analytics teams to develop analytical models, interpret results, extract insights, understand trends, and create solutions to improve population health care delivery and create value
Actively participate in State Fair Hearings, state calls, UM front line work, and appeals as needed
Work with medical director teams on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review, and provider appeals clinical review
Facilitate Interdisciplinary Care Team rounds for DSNP/MMP members
Develop effective working relationships with internal clinical teams, facilitate educational and coaching opportunities, and establish relationships/consult with external agencies

Skills

DSNP

MMP

Clinical Oversight

Utilization Management

Risk Adjustment

Care Management

Medicare-Medicaid

Health Care Delivery

Medical Management

Provider Relations

Regulatory Compliance

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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