Senior Clinical Director, Medical Management
$140,000–$170,000 year
HybridBoston, Massachusetts, United States
Job Summary
Lead development and implementation of Office of Clinical Affairs strategy for medical management to ensure appropriate, efficient, and high quality care delivery. Collect, analyze, and report on medical management metrics to identify trends and recommend interventions. Oversee utilization management initiatives, including prior authorization, concurrent review, and retrospective review, while developing clinical coverage policies and conducting provider reviews. Manage clinical and non-clinical staff executing medical management initiatives and ensure adherence to CMS and regulatory requirements. Collaborate with the Chief Medical Officer on strategic issues and serve as the lead interface with other agency teams. Work 1-2 days per week on site in Boston or Quincy.
Required Qualifications
- Current, unrestricted R.N., C.N.P, or P.A. license in Massachusetts throughout employment with OCA
- Bachelor's degree
- At least 5 years experience in direct patient care
- At least 5 years experience in a leadership position in utilization/medical management in a managed care organization/health plan
- At least 5 years experience supervising clinical staff
- Thorough knowledge of the principles and practices of medical management including utilization management
- Excellent oral and written communication and presentation skills
- Must work 1-2 days per week on site in Boston and/or Quincy during normal business hours
Desired Qualifications
- Demonstrated commitment to serving Medicaid patients
- Thorough knowledge of Medicaid and related regulations
- Certification in case management and/or utilization management
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