New Jersey Community and State MLTSS Medical Director - Hybrid

At UnitedHealthcare, we??e simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing... together.
What makes your clinical career greater with UnitedHealth Group? You can improve the health of others and help heal the health care system. You can work within an incredible team culture, a clinical and business collaboration that is learning and evolving every day, and, when you contribute, you??l open doors for yourself that simply do not exist in any other organization, anywhere.
The NJ MLTSS Medical Director reports to the CMO of the UnitedHealthcare Community Plan of NJ and manages development and implementation of medical expense management initiatives for MLTSS service delivery and program operations. Advises leadership on improvement opportunities regarding medical expense programs and clinical activities that impact medical expense. Accountable for all end-to-end processes, decisions, and outcomes. Manages/Influences/Deliver Communications of Clinical Decisions/Programs/Cases/Results. Develops functional and market level, strategy, plans, production in alignment with organizational priorities. Identifies and resolves technical, operational, and organizational problems across a matrix team structure. Deliver group presentations on clinical programs/data/information at the local market level, to internal and external stakeholders, as approved.
If you are located in New Jersey or a bordering state, you??l have the flexibility to work remotely * as you take on some tough challenges.
Primary Responsibilities
??Performs daily review of private duty nursing, personal care attendant services (as applicable), and other eligible home and community based services outlined in the state contract (i.e., respite, home modification, vehicle modification, medical day care, pediatric medical day care, chore services, long term custodial care, and other services) to approve or deny appropriate services for members as determined to be medically necessary according to state regulations. Will work with nursing staff to clarify requests and documentation, as needed
??Supports nursing staff, operations, and other clinical and non-clinical staff in the transition of nursing facility members to the community when an alternative placement is identified including providing the appropriate service authorizations
??Coordinate and facilitate daily clinical rounds with appropriate staff regarding service authorizations, service delivery, and program operations
??Performs timely reviews as defined in the state contract of critical incident reporting with nursing and quality team members. Reviews for provider trends and recommends appropriate interventions for remediation, if needed
??Actively participates in health plan, state, and other external stakeholder quality management, quality assurance, and performance activities and committees, including IDT (Interdisciplinary Team) conferences for members
??Responsible for understanding and implementing the requirements of MLTSS service delivery, program operations and Care Management as defined in the state contract, especially the supplemental Managed Long-Term Services and Supports (MLTSS) Article(s) of the state contract, including the Appendices and MLTSS Dictionary
??Provides support and effectively engages in all internal and external clinical quality initiatives and peer review processes, audits/complaints/inquiries/reports by state and other regulatory agencies related to MLTSS
??Responsible for preparing for and attending fair hearings related to denied MLTSS services serving as witness for health plan?? utilization management policy and processes and subject matter expertise of MLTSS services. Will work with nursing staff, regulatory team, and legal resources, both internal and external, as it relates to appeals and grievances of MLTSS services
??Responsible for appropriate utilization management including managing/monitoring the results of Care Management/ Health services interventions to ensure that utilization goals are achieved; collaborating with Care Management/ health services/behavioral health, as necessary to maintain focus on achieving targets
??Actively participates in healthcare affordability initiatives and meetings at the local market as requested
??Conducts provider telephonic review and discussion (peer to peer), schedules on-site visits and shares tools, information and guidelines related to cost-effective health care delivery and quality of care as necessary
??Participates in the HEDIS data collection process, CAHPS (Consumer Assessment of Healthcare Providers and Systems) improvement, and drive Health Plan accreditation, LTSS Distinction, Health Equity accreditation activities
??Effectively engages and brings understanding to our external constituents such as physicians, medical and specialty societies, hospitals and hospital associations, and state regulators
??Works toward fully integrated clinical model working with Behavioral Health and clinical management
??Responsible for identifying opportunities through participation in local medical value creation opportunities or market reviews as requested
??Collaborates with the health plan Chief Medical Officer, and other clinical staff or leaders as a clinical resource and coach to establish and implement programs to support and meet the strategic clinical, operational, and financial goals and priorities established by health plan leadership
??Collaborates with the Chief Medical Officer, clinical operations staff, and other market staff to implement programs to support and meet market and national clinical operations goals
??Accountable for providing clinical leadership primarily focusing on home and community-based services review and external communication with network physicians
??May assist in the development and implementation of local plan clinical policies and procedures, quality improvement activities and performance improvement projects
You??l be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications
??MD or DO with an active, unrestricted license in NJ
??Board Certified in an ABMS or AOBMS specialty
??5+ years clinical practice experience, preferably in managing members with complex medical conditions
??2+ years Quality Management experience
??Intermediate or higher level of proficiency with managed care
??All employees working remotely will be required to adhere to UnitedHealth Group?? Telecommuter Policy
New Jersey and New York Residents Only: The salary range for New Jersey/New York residents is $286,104 to $397,743 annually. Salary Range is defined as total cash compensation at target. The actual range and pay mix of base and bonus is variable based upon experience and metric achievement. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you??l find a far-reaching choice of benefits and incentives.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes ??an enterprise priority reflected in our mission.
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment

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