Regional Medical Director - GuideWell Health Plans
Company: Blue Cross Blue Shield of Florida
Posted on: November 10, 2018
The GuideWell Health Plans (GWHP) Regional Medical Director is a transformational leader who possesses the skills to clearly articulate a vision, inspire others, and support the launch of an innovative new model HMO for the local group segment. The GWHP Regional Medical Director is accountable for the clinical and pharmacy program strategy for GWHP and will work closely with the GuideWell enterprise medical operations team to execute the strategy. This role serves as the primary point of contact and is accountable for ensuring the anchor provider partners are able to deliver on the Plan's accreditation, utilization and quality targets. The Regional Medical Director will serve as the physician champion for our anchor provider partners and ensure they are fully leveraging the suite of population health analytics to manage their patient populations. Because of the unique structure our GWHP's operating model, this role requires a high degree of coordination with external and internal business partners, including, but not limited to the providers, health care systems, Prime, Wellness, appeals and grievance, Quality, Case and Disease management, and other vendors who provide care management services to the enterprise. The GWHP Regional Medical Director must possess a solid knowledge of how care management strategy impacts network, customer experience, provide experience, medical costs, provider risk arrangements and the broader value proposition of the GWHP solutions in the market ? with an emphasis on affordability. Job duties include but are not limited to: * Responsible for developing the strategic plan and direction for GWHP's care and pharmacy operating model. This includes managing the execution of the operating model with leaders within the medical operations area * Develops innovative approaches to meet organizational goals and objectives while effectively managing change and administrative costs * Strategize with the GWHP leadership team and other GW leaders regarding program expansion, business development, new care/pharmacy models and establishing appropriate clinical and business targets * Monitor marketplace trends and gather competitive intelligence * Serves as the primary point of contact and is accountable for all aspects of health plan clinical/pharmacy and utilization management performance * Work collaboratively with the provider partners and key health care systems to support achievement of quality initiatives; develop, implement/execute care programs, monitor outcomes of the planned initiatives and adjust tactics as needed to meet targets * Provides leadership, coordination, and direction to achieve effective clinical/pharmacy programs and operational excellence, while focusing on member and provider outcomes * Work closely with the GWHP team to deploy new collaborative provider relationships that recognize and reward improved quality and cost efficiency. This position will serve as a clinical liaison to physicians and hospitals as we transition to new payment and care delivery models which supports more coordinated, efficient and quality-driven healthcare * Lead the design and implementation of targeted interventions to improve the clinical and pharmacy trends as well as RPM / risk coding and the use of value-based insurance design to support care program and ultimately profitable growth for the plan * Design, develop and implement a process to evaluate the cost and operational effectiveness of the care and pharmacy programs * Represents Guide Well Health Plans, as requested, on all provider, care, and pharmacy related matters while leveraging key relationships with professional organizations to influence practice and legislative policy and regulatory requirements * Works collaboratively with IT and Analytics to develop new analytics solutions that support GWHP's anchor provider partners * Remain current related to issues affecting the care and pharmacy industry and coordinate with organization on best practice strategies * Participates in discussions with care and pharmacy business partners related to the development and implementation of health plan specific policies & SOPs to support UM/care management strategies and contractual requirements, CM interventions, and administrative functions and ensures regular reviews and maintenance processes are in place * Leverage and integrate team expertise and skillsets within the organizational to drive different perspectives and outcome excellence * Provides clinical expertise to care and pharmacy programs and works closely with providers and hospitals, as well as various areas throughout the Care organization * Develop effective partnerships with key leaders within Sales/Marketing, Compliance, Medical Operations, Care Management , Service Organization, Network, Service, Product, Actuarial and Legal * Works with the pharmacy team to to ensure compliance with all contractual terms of GWHPs agreement with Prime ? including compliance State and Federal regulations * Local market SME for all clinical/pharmacy management programs and contractual requirements ? including market expansion activities beyond South Florida Job Requirements: * 7 years related work experience or equivalent combination of transferable experience and education * 5 years direct supervisory/management experience * Board certified in primary specialty * Licensed to practice medicine in the state of Florida without restriction * Comprehensive understanding of medical economies and performance metrics * Experience leading the administration of medical management programs * Ability to act decisively * Entrepreneurial and innovative abilities * Knowledge of the healthcare and insurance industry, managed care products/benefits and programs * Strong verbal and written communication skills * Managed care experience * Demonstrated ability to develop productive and collaborative working relationships with key internal and external stakeholders Preferred: * Demonstrated knowledge and application of the Florida Blue Management System * Demonstrated knowledge and application of the profession of pharmacy as it relates to clinical pharmacy knowledge, Florida Pharmacy law, and the process flow for prescription drug services in the state of FloridaSDL2017
Keywords: Blue Cross Blue Shield of Florida, Jacksonville , Regional Medical Director - GuideWell Health Plans, Executive , Jacksonville, Florida
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