Published

February 2, 2024

Location

Albuquerque, NM

Description

In conjunction with the Chief Medical Officer, Executive Director Population Health and Executive Director Behavioral Health, the Senior Medical Director is responsible for clinical program oversight and operation of behavioral and population health services, including population health strategies and programs and behavioral health clinical program development, implementation, integration, evaluation, and improvement.

Along with CMO, sets strategy and provides accountability for advancing health equity and ensuring mental health parity across all PHP populations. Provides leadership and strategy for meaningful use of data and analytics, including social determinants of health, to identify innovative clinical program opportunities and ensures implementation. Provides clinical solutions to ensure behavioral health access, assures mission and goals and strategies of PHS/PHP are met, and is accountable for strategic planning, operational management, dynamic leadership and fiscal accountability. Represents PHP at state and national level forums and is responsible for fostering collaborative relationships with the State and Federal partners, plan members, participating providers, partners, and the community. Ensures compliance with State and Federal and accreditation requirements.

Responsibilities

Sets policy and strategy and provides accountability for behavioral and population health programs, including meaningful use of data and analytics to inform, measure, and refine programs that meet the needs of PHP populations.
Provides clinical direction and support to operational teams including care coordination, population health clinical program development, disease management, clinical process re-design, provider profiling, and prevention and wellness programs, as well as any program types yet to be developed.
Primary responsibility for direction of PHP Centennial Care Behavioral Health clinical and integration activities as well as clinical strategy for all lines of business
Provides clinical oversight of the behavioral health vendor and functions
Provides clinical strategy for behavioral health HEDIS and other quality metrics, including metrics to be included in value-based arrangements
Terminal medical decision maker for behavioral health utilization management and quality management programs.
Leads research and development of behavioral health medical policies and provides key leadership support for advancing health equity in the development and revision of medical policies, both behavioral health and physical health.
Furthers PHPs population health program clinical gating and subpopulation criteria.
Oversees the Medical Directors in daily medical and care management, quality improvement, and other activities as well as external-facing and other stakeholder functions.
Coordinate on all behavioral and population health functions performed internally or through vendor partners to PHS/PHP, including but not limited to customer service, network contracting and management information systems, pharmacy, care management, quality improvement, program integrity, long term care, and others to assure that the unique features of health services functions are considered and addressed.
Monitors and assists in the implementation of a quality, cost effective population health program.
Participates in all appropriate committee activities within the Population Health and Quality committee structure.
Participates in relevant strategic and benefit planning sessions.
Ensures compliance with CMS, HSD, DOI and all other regulatory agencies.
Supports PHP in achieving and maintaining NCQA, CMS, IPRO and all other accrediting requirements.
Supports efforts of PHP in developing and communicating physician practice profiles.
Develops and maintains key provider and community collaborative relationships and ensures that all activities and processes support patient care, reduce unnecessary barriers, and optimize physician engagement. This includes relationships with network practitioners, key stakeholders as well as local and State entities such as HSD, CYFD, OSI, EQRO, and DOH.
Assists in the development of strategic plans for addressing quality and healthcare cost management concerns and opportunities for Government Programs. Responsible for recording/communicating progress toward meeting any outlined strategic objectives and/or goals.
Liaison with State of New Mexico HSD and CMS relative to behavioral health, population health, quality improvement, and behavioral health care coordination programs and performance.
In tandem with CMO provides clinical oversight of behavioral health aspects of UMPD/PE, QMPD/PE, Population Health PD/PE, and related work plans.

Quality Management, Clinical Quality Committee

Accountable for quality improvement efforts consistent with Centennial Care, Medicare, and Dual Plus clinical performance measures.
Participates in ongoing identification, design, and development of clinical practice guidelines/disease management programs, prevention and wellness initiatives, clinical Quality Improvement Activities (QIAs) incorporating both national standards and local physician input. Serves on PHP UR/QA Committee to assist in development of clinical practice guidelines.
Participates in development and implementation of an outcomes-oriented PHP Quality Management Program for Centennial Care, Medicare, and Dual Plus programs.
Provides oversight of behavioral health quality of care complaints and participates in peer review functions, including relevant committees and process improvement initiatives that involve this function for all lines of business.
Assists with medical necessity determinations in the Pharmacy prior authorization process. Serves as an advisor to department staff in any process improvement initiatives that involve this function.

Additional Key Functions

In tandem with the CMO, ACMO, and other members of the Senior Medical Leadership Team, coordinates medical management grievance and appeals functions and case review.
Acts as liaison to external health organizations/committees.
Performs other functions as required.

Qualifications

M.D. or D.O. degree, with board certification in Psychiatry.
Five years clinical practice experience and currently licensed to practice in New Mexico without restriction.
At least five years experience in a managed care setting that includes responsibility for integrated care management (physical, long term care, behavioral health, population health) including Medicaid and Dual Medicaid/Medicare enrollees.
Experience crafting, implementing, monitoring, and championing clinical practice guidelines, resource utilization, and cost management initiatives both with internal staff and delegated entities (Patient Centered Medical Homes, Health Homes, networks). Coursework or formal training in business desirable (e.g. M.B.A. or M.P.H. degree, courses sponsored by ACPE). Previous experience and training in Child and Adolescent Psychiatry desirable, as further training and expertise is expected in this role.
Requires detailed knowledge of population health, and care management principles and serves as a resource or educator to other practitioners. Sound understanding of managed care environment, including various financing mechanisms (e.g., capitation), along with health related social and behavioral health needs of New Mexicans. Familiarity with National Committee for Quality Assurance (NCQA) and with Health Plan Employer Data and Information Set (HEDIS) principles and requirements.
Ability to make decisions that require significant analysis, investigation, and original thinking.
Ability to determine appropriate courses of action in complex situations that may not be addressed by existing policies, procedures, or protocols. Decisions include such matters as application of new or established procedures, determination of the order in which work is done, and identification of the resources necessary to achieve desired outcomes.
Ability to, sit, lift moderate weights, and perform coordinated arm/wrist/hand movements. Some travel by automobile required.