Vice President, Chief Medical Director CHRISTUS Networks
Location: Irving, Texas
Internal Number: 9878802
The Vice President, Chief Medical Director, CHRISTUS Networks is responsible for the direction and oversight in appropriateness and medical necessity of health services, quality metrics and outcomes, Pharmacy utilization and formulary, and for the Health Plan specifically, all aspects of care management, utilization management and disease management activities. In carrying out the responsibilities of this position, the Vice President works closely with the Health Plan, ACO and CIN Vice Presidents and functional area direct reports. The Vice President may have interaction and has consultations with practitioners in the field as required in order to perform the duties of the position. The Vice President ensures through his/her role and functions to provide improvement in the overall areas of for the Health Plan of Care Management, Quality, Medicare Advantage and Marketplace Plan STARs improvement and success, CAHPS, HEDIS metrics and Pharmacy.
Graduate of an accredited Medical School.
Current unrestricted license to practice medicine in one or more of the following states: Texas, Louisiana, New Mexico.
Knowledge of NCQA, HEDIS, STARs performance, Medicare, State and Federal programs.
Experience in clinical practice preferred but not required.
Three (3) years or more Managed Care Payor experience preferred but not required.
Knowledge of group and individual physician practices working together in a network situation.
Pharmacy formularies and health plan benefit coverage beneficial.
Licenses, Registrations, or Certifications:
Prefer current and unrestricted Medical licensure in one or more of the States where CHP operates (Texas, New Mexico and LA).
Provides leadership to Health Plan physical and behavioral health medical management programs.
Provides leadership to daily determinations electronically or telephonically of medical necessity and appropriateness within the utilization management and appeals processes.
Provides leadership to physician review services for case management, quality management and peer-to-peer determinations.
Provides leadership to UM nurse team managing the authorization and denial process.
Provides leadership to case reviews with BH vendor, clinicians, and external treating providers as appropriate.
Recommends clinical programs to improve health outcomes of health plan members.
Adhere to code of confidentiality following the CHRISTUS Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
Advocate Accrediting agency standards as needed in carrying out role of Vice President for the health plan.
Maintain current knowledge of state and federal regulations, standards, and practice guidelines.
Communicates, collaborates and coordinates with various providers and Associates as necessary in the performance of duties.
Provides leadership to Physician review of cases referred for coordination of health care management activities.
Communications directly w/Networks physicians on cases referred for review.
Works with individuals and groups of physicians to modify clinical performance in order to meet plan requirements and goals.
Attends or Chairs committees as required such as Credentialing, Quality and Physician Advisory Council/Peer Review Committee.
Provides leadership to Credentialing Program on an ongoing basis at least monthly.
Provides leadership on Plan Medical Policies.
Fosters evidence based clinical practice guidelines.
Reviews key performance indicators to independently identify over and underutilization patterns, analyzes variances and formulates corrective actions for recommendation and implementation.
Reviews Benchmarks and evaluates utilization and cost trends in medical management.
Provides leadership on projects for continuous process improvement of medical management functional areas.
Responsible for ensuring Health Plan compliance with regulatory (State, CMS, DOD) and accreditation (NCQA, AAAHC) entities.
Supports Health Plan quality work plan initiatives.
Accepts Fiduciary Responsibility to the Texas Department of Insurance to provide independent medical judgments with special emphasis upon vulnerable populations, include pregnant women, children & behavioral health patients.
Assists network management in recruiting physicians to our Health Plan networks in underserved areas where specific network deficits exist.
Knowledge and experience with Value-Based Care arrangements.
Knowledge and experience with Medicare FFS Shared Savings and Risk programs. Interact collaboratively with the Clinical Leadership of CHRISTUS Health including CLG, CPG & CIN to ensure alignment with the Regional CHRISTUS Enterprise.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.