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011200 CCA-Central Clin Ops Leadership

Position Summary:

Reporting to the Sr. Medical Director of Utilization Management (UM) and Policy, the Medical Policy Director, provides strategic and tactical leadership and oversight for the development, implementation, and evaluation of policies related to medical, behavioral health, and social determinants of health services specific to the population serviced by CCA. The Medical Policy Director is an independent contributor who works in partnership with medical leadership and cross-functionally in the organization. The Medical Policy Director ensures that the medical policies align with the organization’s clinical and operational goals, meet regulatory, accreditation, and contractual requirements, and aligned with industry standards, evidence, and best practices.

Supervision Exercised:

+ No, this position does not have direct reports.

Essential Duties & Responsibilities:

The Medical Policy Director’s main responsibilities are as follows:

Strategic Leadership: Lead the vision, strategy, and roadmap for medical policy development and implementation, ensuring alignment with enterprise-wide clinical and business objectives.

+ Responsible for staying abreast of all state and federal mandates, contract, regulatory and policy changes, and workflows impacting Medical Policies and related outcomes

+ Responsible for understanding the population CCA serves

+ Responsible to understand medical policy decision impact on Member, Provider, Regulator, and Contractual documentation/ communications.

+ Research, analyze, and develop medical policies in compliance regulatory, accreditation, contractual requirements as well as industry standards and best practices

+ Monitor emerging healthcare technologies and products and develop recommendations for coverage

+ Manage the development of new and review of existing medical necessity guidelines by working closely with clinical staff by completing competitor, market and clinical research while aligning policy and practice with the needs of the populations.

+ Evaluate the effectiveness of the company’s medical policies and prior authorization program in collaboration with other leads, including via reporting and via facilitating an annual evaluation

+ Make recommendations for the acquisition of tools and resources to support the research needs of the Medical Policy staff, as needed

+ Demonstrate knowledge and understanding of the laws, regulations, CCA’s contracts and policies that pertain to CCA’s business and conforms to these laws, regulations, and policies in carrying out the position duties and responsibilities.

+ Be a subject matter expert in medical policies including advising leaders and departments

+ Perform special projects as assigned by management

Operational Policy Governance: Oversee the governance structure for medical policy review and approval, ensuring transparency, consistency, and compliance with federal and state regulations.

+ Ensure end-to-end workflows are streamlined and maintained

+ Develop and maintain systems for tracking medical policy reviews and revisions.

+ Ensure at least annual review or as needed metrics are met

+ Ensure accurate, up-to-date versions are uploaded in the database and online

+ Documenting or maintaining status reports, meeting minutes, issue/risk logs, interview guides, and project plans related to MP work

+ Developing PowerPoint presentations, policy cases and policy summary briefs

Cross-Functional Collaboration: Partner with executive leaders in Clinical Operations, Quality, Compliance, Legal, Pharmacy, Behavioral Health, and Population Health to ensure policies are evidence-based, equitable, and support value-based care.

+ Seek input from appropriate experts and stakeholders

+ Provide education and training around medical policies as needed

+ Collaborate effectively with internal business areas such as payment policies and claims to ensure alignment between other CCA areas and medical policies

+ Communicate the changes of medical policies via notification and/or training and disseminate updated medical policies according to company policies, state, and federal guidelines internally and externally to CCA’s provider community

+ Collaborate with other departments regarding provider manuals and internal training materials to ensure materials are consistent with policies and state and federal guidelines

+ Presenting updates, findings, and recommendations to clinical leadership, peers and associates at all levels as applicable for assigned projects

Working Conditions:

+ Standard office conditions. Fully remote

Required Education (must have):

+ Bachelor’s degree from an accredited college or university or equivalent professional experience required

+ Lean Six Sigma Green Belt

Desired Education (nice to have):

+ Masters in Public Health, Healthcare Administration, or similar education and training

+ Degree in nursing or a health-related field preferred

+ Lean Six Sigma Black Belt

+ Artificial Intelligence (AI) certification or training

Desired Licensing (nice to have):

+ Active clinical license, e.g. nursing, physical therapy, LICSW

+ Certified Professional Coder (CPC)

Required Experience (must have):

+ minimum 5-7 years’ experience in the health care delivery system/industry or public health/public policy sector

Desired Experience (nice to have):

+ 10 years of experience in medical policy, utilization management, clinical program leadership within a health plan, integrated delivery system, academic, or regulatory body

Required Knowledge, Skills & Abilities (must have):

+ Demonstrated competence with policy research and development within a health plan, government agency, regulatory or accreditation body

+ Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.

+ Demonstrated ability to deliver highly technical information to less technical individuals.

+ Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

+ Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment.

+ Proven ability to exercise sound judgment and strong problem-solving skills.

+ Proven ability to ask probing questions and obtain thorough and relevant information.

+ Must be client service focused with effective ability to empathize.

+ Must be proficient in the use of PC and various claim systems

+ Must be proficient in the use of computers, specifically Microsoft Office products. Must have proven ability to learn new systems and databases that CCA implements.

+ Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.

Required Language (must have):

+ English

Desired Knowledge, Skills, Abilities & Language (nice to have):

+ Proven experience leading in matrix and cross-functional roles

+ Strong analytical, strategic thinking, and communication skills

+ Policy brief development

+ Policy Analysis

+ Data analysis

+ Power point, excel and word proficiency

+ Medical Billing and Coding Certification

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.