Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

 

The Medical Director, Population Health (MDPH) is a data-driven leader responsible for designing, harmonizing, and overseeing clinical programs across the Capital enterprise. The MDPH role is primarily focused on Capital’s Medicare Advantage MA Lines of Business, with responsibility to serve as the lead physician on clinical strategies spanning Quality, Risk and Total Cost of Care (TCOC). This role will be approximately 70% administrative and 30% clinical, with member-level support for utilization management activities and clinical oversight functions for care management and strategic provider partnerships.

• Lead clinical oversight for key MA partnerships across both internal functions such as network provider operations and external strategic partnerships with both digital and traditional clinical programs.
• Partner across Population Health, Government Programs and Provider Network leaders to evaluate the efficacy of existing clinical programs, and design clinical and operational strategies to optimize performance.
• Physician lead for quality management functions and market-facing representation to the provider network. Engage value-based care partners to enhance performance outcomes; leading, designing and driving scalable practice & provider engagement for MA STARS, TCOC & Risk programs.
• Thought leader influencing Medicare TCOC and affordability strategies, including utilization management (UM) trend control and UM process improvement initiatives. Assist in review and implementation of UM and medical policy, including recommendations for improvements to enhance efficiency, quality and effectiveness.
• Integrate pharmacy and medical care strategies, acting as a bridge partner with Capital’s pharmacy benefits manager and serving as internal subject matter expert on MA formulary design.
• Leverage existing analytics tools and assist in enhancing data products as critical infrastructure to design new clinical strategies and manage the performance of existing clinical programs.
• Work in collaboration with UM and Care Management (CM) to understand utilization trends and develop programs to address inappropriate utilization, readmissions and achieve MLR targets. Chairs high-cost claimant rounds across all LOBs.
• Clinical committee oversight including functions such as member safety, credentialing, Medicare appeals review and strategic partner Joint Operating Committees.
• Data-driven leadership aligns CMS compliant MA strategies to mitigate regulatory compliance risk while tracking and driving progress towards Capital’s annual goals.
• Renders medical management decisions that are member-centered, quality-first and holistically address clinical, psycho-social member needs. Leads a culture of evidence-based clinical decisions through sponsorship of population health care management rounds and member case reviews.
• Documents in medical management systems to memorialize clinical review, plan of care and coverage decisions. Works with network provider partners to access and use electronic health records, periodically supporting chart reviews for MA risk strategies.
• Support Chief Medical Officer, Vice President of Population Health and Government Programs stakeholders with other duties as assigned.

Skills & Knowledge:

• Outcome oriented, excellent cross-functional leadership and communication skills.
• Quality-first mentality with working knowledge of healthcare operations.
• Demonstrated healthcare improvement and change management success.
• Strong data orientation, with basic self-serve analytics capabilities.
• Leads and manages effective meetings, builds trust and rapport across teams.
• Familiar with the Medicare policies & practices promulgated by CMS that impact members, provider networks, and managed care organizations.
• Deep understanding of healthcare strategy and interconnected payer/ provider care ecosystems.
• Deep understanding of and appreciation for rapid health-tech evolution, including digital health solutions and the incorporation of Artificial Intelligence (AI) across clinical care & operations.
• Knowledge of Health Plan operations related to both Commercial and Medicare LOBs.

Location:

• The preferred classification for this position is hybrid, which would require onsite work on Tuesdays and Wednesdays. 

Experience:

• A minimum of five years of clinical experience, post residency, including both inpatient and outpatient care.
• At least three years’ experience in managed care, utilization review, and/or quality management.
• At least three years’ experience leading clinical program design and optimization for a Medicare population.
• At least three years’ experience applying clinical guidelines to measure, benchmark and influence provider practice patterns and population outcomes.

Education and Certifications:

• A medical degree (M.D or D.O) and active, unrestricted medical license in Pennsylvania. Must obtain licensure in all Medicare markets upon hire.

• Must be clear of any sanctions by the applicable state of Office of the Inspector General.
• Must not be prohibited from participating in any Federally or State funded healthcare programs.

Physical Demands:

 

While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.