This position has been filled.

Vice President, Medical Policy and Utilization Review

Commonwealth Care Alliance

  • Location: Boston, MA

Commonwealth Care Alliance (CCA) is a not-for-profit, community-based healthcare organization dedicated to improving care for individuals who are dually eligible for MassHealth (Medicaid) and Medicare with complex medical, behavioral health and social needs, including those with disabilities. With nearly 36,000 members, CCA offers two plans, Senior Care Options (HMO SNP) and One Care, a Massachusetts demonstration program for dual eligible individuals.  For three consecutive years, CCA’s One Care plan received a top consumer rating for quality and access in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) national survey of Medicare-Medicaid Plans (2016, 2017 and 2018). For 2020, CCA’s Senior Care Options received 4 Stars according to the U.S. Centers for Medicare & Medicaid Services Star Ratings.

In addition to its health plans, CCA offers Commonwealth Community Care centers comprised of primary care, disability-competent community care centers, community-based Crisis Stabilization Units, and a health innovation accelerator in partnership with Winter Street Ventures.

Position Overview

In this newly created role, the physician leader will be responsible for providing clinical leadership and subject matter expertise to the Medical Policy and Utilization Review functions. This clinical executive will be instrumental in helping the organization provide high quality, equitable care to a rapidly growing dually-eligible membership and will be responsible for physician utilization review and the creation and management of a robust set of in-house, evidence-based medical policies and medical necessity guidelines.  The Vice President will utilize exceptional clinical judgement, communicate effectively at all levels, and lead a diverse team to improve operations and efficiency.

Qualifications

  • Board Certified MD or DO with current license to practice in Massachusetts or the ability to obtain licensure required.
  • Utilization management experience required, as is a minimum five years of progressive business experience.
  • Five or more years of medical management and general management experience in a managed care environment is strongly preferred.