Senior Medical Director (Fully Integrated Duals ...

Job DescriptionPrimary Responsibilities Responsible for clinical oversight of DSNP/FIDE complex populations (Duals Special Needs / Fully Integrated Duals Eligible) Develop and lead clinical strategy and objectives for the DSNP/FIDE populations, including the development and implementation of clinical initiatives and programs to address the needs of the populations managed to improve health outcomes Leverage extensive knowledge of health care delivery system, utilization management, reimbursement methods and treatment protocols for DSNP/FIDE and other complex health populations to optimize risk adjustment, clinical quality, and care management Actively participate in meetings and communication with the state Departments of Medicaid Outward facing position to interact and collaborate with medical / physical professional associates, the local provider community, state regulatory agencies and advocacy groups to advance clinical excellence and the delivery of cost-efficient care. Will also Interact with the members, health systems, nursing facilities, as well as home and community-based networks Develop and guide the implementation of medical management programs to ensure providers deliver appropriate, high-quality, cost-effective health risk assessments and other clinical services that are evidence-based Work collaboratively with the 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 In collaboration with health care analytics teams, develop analytical models, interpret results, and extract insights on the clinical drivers and trends and tracks data to improve the delivery of population health care to create value for members, providers, and the health plan Be able to effectively communicate these finding to Senior Management and staff at all levels Develop and deliver conference presentations or other presentations (written or oral) that support the health plan in a professional and effective manner Actively participate in State Fair Hearings as needed Confer directly with providers regarding the care of patients with severe, complex, and/or treatment resistant illnesses through peer review and educational interventions Work with medical director teams focusing on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review, and provider appeals clinical review Actively participate in scheduled team meetings and leadership meetings, at the health plan, local, state, regional, or national levels Facilitate interdisciplinary care team rounds for DSNP/FIDE members Develop effective working relationships with internal clinical team, facilitate educational and coaching opportunities for the internal clinical team, as well as establish relationships and/or consult with external agencies in pursuit of the IHI Triple Aim Partner with appropriate entities in the investigation of potential quality of care concerns and/or grievances Actively support compliance functions to maintain standardized systems, policies, programs, procedures, and workflows that ensure the health plan exceeds care management, regulatory, and quality standards Support the activities of the Chief Medical Officer and other plan leadership as required or assigned Be an active voice and participate in all internal and external committee meetings Actively participate in quality improvement activities internal and external to the organization with multiple stakeholders Help achieve or exceed all applicable HEDIS, Stars and local state performance targets and goals otherwise specified for the plan Support all Clinical Quality initiatives and peer review processes including Quality of Care and Quality of Service (grievance) issues Actively participate in or lead quality and/or member/provider service-focused committees Provide clinical leadership in preparation for program audits and/or certification processesPay RangeThe typical pay range for this role is:Minimum: 162600Maximum: 348000Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required QualificationsRequired Qualifications MD or DO degree Current and active, unencumbered, and unrestricted physician licenses in NJ and NY Active/unrestricted Board Certification in ABMS or AOA specialty 5+ years of clinical practice experience post residency, including experience with complex health populations and services (must have at least three years of training in a medical specialty) 3+ years of experience in the managed care industry Solid understanding of LTSS/MLTSS Experience in leading inter-disciplinary teams Solid understanding of and concurrence with evidence-based medicine (EBM) and managed care principles Domiciled in the State of New Jersey Ability to travel on as needed basis Proven ability to develop relationships with network and community physicians and other providersCOVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred QualificationsPreferred Qualifications Experience with managing LTSS/MLTSS patients/membersProject management or active project participation experience Substantial experience in using electronic clinical systems Solid data analysis and interpretation skills; ability to focus on key metrics Demonstrated team-player and team-building skills Proven strategic thinking with proven ability to communicate a vision and drive results Solid negotiation and conflict management skills Demonstrated creative problem-solving skillsExperience Clinical experience pertinent to the complex patient population(s) being managed Experience in managed care and value-based programs Solid experience in end-of-life issues Experience with cost-benefit analysis, medical decision analysis, quality assurance and continuous quality improvement processes Solid knowledge of health insurance industry trends, reimbursement methods, and evolving accountable care and payment models Passionate about new/innovative and specialized models of care within the delivery system Well-versed in with extensive experience with key-driver diagrams, flowcharts, check sheets, Pareto diagrams, cause and effect diagrams, histograms, scatter diagrams, run and control charts Well-versed in value-based contracting modelsEssential Skills/Experience Solid critical thinking and problem-solving skills Ability and desire to lead and continuously improve and evolve programs Solid verbal and written communication skills, including ability to present and speak in public forums Collaborative spirit - internal and external to the organization Flexibility in daily work schedule and task assignment Managed care experience Proven ability to prioritize and multi-task Advanced skills in MS Office Provide ongoing coaching and feedback with colleagues and other team members to ensure peak performance Focus staff on the company's mission and values Demonstrate pro-active, solution-oriented approaches to work efforts and drive disciplined, fact-based decisions Ability to focus energy on serving the patient Execute with discipline and urgency Drive change and innovation though continually seeking and implementing novel solutions Demonstrated ability to create a culture that thrives on continuous change Ability to inspire people to stretch beyond their comfort zone Experience in challenging "the way it has always been done" Model and demand integrity and compliance with all company policies, and local, state, and federal regulations Proven ability to execute and drive improvements against stated goals Ability to develop relationships with network and community physicians and other providers Ability to successfully function in a matrix organization exhibitingEducationMD or DO boarded in a primary care specialty (Internal Medicine, Family Medicine, Geriatrics)Business OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-15