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Senior Medical Director-Operations

Company: Evolent Health
Location: Baton Rouge
Posted on: September 22, 2022

Job Description:

Your Future Evolves HereEvolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Evolenteers make a difference wherever they are, whether it is at a medical center, in the office, or while working from home across 48 states. We empower you to work from where you work best, which makes juggling careers, families, and social lives so much easier. Through our recognition programs, we also highlight employees who live our values, give back to our communities each year, and are champions for bringing their whole selves to work each day. If youre looking for a place where your work can be personally and professionally rewarding, dont just join a company with a mission. Join a mission with a company behind it.Why Were Worth the Application:

  • We continue to grow year over year.
  • Recognized as a leader in driving important diversity, equity, and inclusion (DE&I) efforts ( .
  • Achieved a 100% score two years in a row on the Human Rights Campaign's Corporate Equality Index making us a best place to work for LGBTQ+ equality.
  • Named to Parity.orgs 2020 list of the best companies for women to advance ( .
  • Continued to prioritize the employee experience and achieved an 87% overall engagement score on our last employee survey.
  • Published an annual DE&I report ( to share our progress on how were building an equitable workplace.What Youll Be Doing:Senior Medical Director-OperationsWho you will be working with:In this role, you will join the Evolent Senior Medical director team, which is made up of three leaders with each individual leading predominantly in Operations, Quality, and Behavioral. These leaders also ensure appropriate utilization and innovative clinical programs for Evolents clients members.Operations LeaderThe Senior Medical Director-Operations (SMDO) primary responsibility is oversight of the work of the medical director staff. The SMDO is responsible for implementing and sustaining a metric-driven culture where data, medical evidence, and effective processes are used to monitor performance and drive decisions. The SMDOs time is divided 33/67 between leadership duties and working directly in an operating capacity.Leads the team of medical directors tasked with providing Utilization and Case Management services (i.e. operations).Acts as a resource to all departments for divisions of the company, particularly the clinical UM and CM staff, for all operational functional areas within EHS. The SMDO is the internally facing leader of the physicians.Provides leadership support for medical management programs, including the evaluation of medical policies, procedures, protocols and systems to support and promote the appropriate and cost-effective use of clinical resources.Provides leadership for annual Prior Authorization (PA) review for Clients, promoting a cost-effective approach to care and resources.Oversees UM Medical Director performance to assure the accuracy and effectiveness of decision making and productivity targets are achievedOversees the scheduling of work hours to assure required coverage at all timesCollaborates with the SVP of UM (Nursing) in the overall planning, budgeting and strategy development of the Evolent UM programCollaborates with the SVP of UM in ongoing program managementRoutinely evaluates UM policies and procedures and champions enhancements as appropriateEvaluates and monitors the performance of third-party UM resources (ex: IROs, outsourced BH, etc.) and coordinates as neededCreates policies, procedures, and develops workforce management process to ensure that queue work is efficient, timely and complete.Partners closely with our pharmacy team to establish policies, procedures and protocols to support the appropriate and cost-effective use of pharmaceutical Prior authorization.Provide input for clinical data capture, analysis and reporting activities. Provide input for development of benchmarking data/standards, evaluation mechanisms, outcome measurements and clinical systems innovations.Provide assistance and support for provider relations, network development and provider cost and use activities in conjunction with the Market team.Develops and evaluates systems and processes, partners with product and data science to drive optimization with the medical directors work.Understands and drives physician related compliance related to Federal (e.g., CMS), State (e.g., Insurance commission) and local rules and regulationsProvides leadership, guidance and interpretation on issues of medical appropriateness, benefit application as appropriate, level of care necessary to include out-of-network care.Develops and ensures, appropriate policies, procedures, and workflows are designed, trained and implemented with end-to-end execution.Responsible for executing and maintaining Evolents benchmarked Utilization/Cost Management Program and relevant Clinical Quality Improvement Programs and Operations.Responsible for a 1/3 management duties and 2/3 operations queue workOther duties as assigned may include but not limited to the following:Supports pre-admission review, utilization management, and concurrent and retrospective review and A & G processes.Participates in risk management, claim adjudication, pharmacy utilization management, catastrophic case review, outreach programs,Participate in the Appeals and Grievance process, as necessary, to assure timely and accurate responses to membersSupports design and implementation of health plan medical policies, and appropriate Care Management and UM goals and objectivesPromotion of managed care systems using evidence-based medicine to educate and facilitate best practices with care management staff and medical providersParticipate in committees as assignedKey Measures of Success:Medical Director staff productivityInternal and External satisfaction surveysClient performance measures such as TAT, LDs, audit and quality results are met or exceededQuality audit results from accrediting and regulatory bodies 3 year or minimal findings, lack of ICARs or CARsQuality audits for the physicians are meeting or exceeding 95%Inter-rater Reliability (IRR) audits for physicians are meeting or exceeding 95%Annual review of all clients Prior authorization listingAutomation results met or exceeded, and rules are approved and signed offThe Experience Youll Need (Required):Graduate of an accredited medical school. M. D. Degree is required. Active physician license without any restrictions.3-5 years of clinical practice in a primary care setting and progressively responsible medical administrative experience preferred.2-3 years of direct operating experience in payor-based Utilization and/or Case Management.Finishing Touches (Preferred):Proven ability in medical leadership position possessing clinical credibility with peers and the ability to be a team player and team builder.1-3 years of experience with physician direct reports, accountability for physician performance or other significant leadership of physicians.Viewed by others as a natural leader even without a formal leadership role.A thorough understanding of all aspects of managed care, including HMOs, PHOs, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, pharmacy management, and patient centered medical home concepts.Detail oriented with a proven ability to manage variability within ongoing operations.Excellent interpersonal, verbal, and written communication skills.Consistently completes continuing education activities relevant to practice area and needed to maintain licensure.Ability to navigate in a corporate matrix environment.Technical Requirements:Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.Evolent Health is committed to the safety and wellbeing of all its employees, partners and patients and complies with all applicable local, state, and federal law regarding COVID health and vaccination requirements. Evolent expects all employees to also comply. We currently require all employees who may voluntarily return to our Evolent offices to be vaccinated and invite all employees regardless of vaccination status to remain working from home. Certain jobs require face-to-face interaction with our providers and patients in client facilities or homes. Employees working in such roles will be required to meet our vaccine requirements without exception or exemption.Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.

Keywords: Evolent Health, Baton Rouge , Senior Medical Director-Operations, Executive , Baton Rouge, Louisiana

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