University of Pittsburgh Medical Center (UPMC) is a $21 billion health care provider and the largest nongovernmental employer in Pennsylvania, integrating 90,000 employees, 40 hospitals, and 700 doctors’ offices and outpatient sites. Working in close collaboration with the University of Pittsburgh Schools of the Health Sciences, UPMC shares its clinical, managerial, and technological skills worldwide through its innovation and commercialization arm, UPMC Enterprises, and through UPMC International.
UPMC Insurance Services Division provides health coverage and benefit management for 3.9 million members, and includes UPMC HealthPlan, Workpartners, UPMC for Life, UPMC for You, UPMC for Kids, UPMC Community HealthChoices, and Community Care Behavioral Health. UPMC Insurance Services Division offers a full range of group health insurance, Medicare, Special Needs, CHIP, Medical Assistance, behavioral health, employee assistance, and workers’ compensation products and service. UPMC Health Plan is among the nation’s fastest-growing health plans and the largest insurer in western Pennsylvania. UPMC Health Plan’s network includes 40 UPMC-owned hospitals, nearly 29,000 primary and specialty care physicians, over 100 community and neighborhood hospitals, and more than 65,000 pharmacies.
Under the administrative direction of the UPMC Insurance Services Division Chief Medical Officer, this senior leader will serve as a strategic, collaborative business partner and is responsible for the clinical strategy, operations, and compliance for the medical management areas of UPMC Health Plan, including utilization management (UM) and medical policy. This position will also have strategic oversight and responsibility for utilization management of all products and services, working closely with senior clinical line of business leadership. This position will oversee utilization management and medical policy senior physicians, serve as the authority on medical management issues and is responsible for compliance with all clinical medical policies, directives, rules, regulations and clinical performance standards of state and federal governments and all accrediting bodies for all lines of business, to include Commercial, Exchange, Medicare Advantage, Medicaid, CHIP and Community Health Choices. In addition, this leader will be the primary physician consultant to the Quality area of the Health Plan, collaborating with the VP of Quality for those items requiring physician input or oversight.
This senior leader is accountable for ensuring the membership receives exceptional service and that clinical outcomes meet or exceed all standards or benchmarks. Taking an integrated approach to healthcare and collaborating with internal and external stakeholders, this Vice President will assure best standards of practice; promote cost-effective, data-driven practice patterns; encourage person-centered, recovery-focused care models and policies; and seek continuous improvement in the medical management areas. He/she will directly interact with physicians, hospitals, medical groups and related networks, direct and respond to risk management issues, and monitor and implement programs to improve the quality of medical services provided. This key physician leader will also be responsible for interfacing with UPMC payer/provider clinical leadership (physicians, hospitals, physician practices and related networks) to further insure effective and efficient clinical care through medical management initiatives.
*Remote work flexibility will be considered.
- MD/DO or equivalent degree. Medical licensure required.
- Master’s degree in business or health related field preferred.
- Senior level manager with at least five years of experience in health care delivery systems management in a managed care environment.
- Strong Medical Policy and Utilization background with a working knowledge of finance, management information systems, and statistical analysis.
- Direct experience with NCQA accreditation for managed care organizations. This would include governmental (Medicare Advantage, Medicaid) and commercial lines of business (Commercial Fully insured, Exchanges, CHIP).
- Knowledge of an experience with regulatory requirements for the delivery of health plan UM and medical policy.
- Must demonstrate competency in interpersonal skills and political savvy, analytical, communication, and problem-solving skills, clinical proficiency, team and customer service orientation, the ability to deal with ambiguity and “out of the box” thinking.
- Must possess the ability to interact on an academic as well as community-based level.
- Knowledge and experience with regulatory requirements for delivery of Medical Management services.