Senior Medical Director - Medicaid LTSS & SAI Lead

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Job Purpose and Summary :

The LTSS / SAI National Senior Medical Director, reporting to a Regional CMO of Medicaid, will collaborate with Aetna National Medicaid, Regional and health plan leadership to identify, develop, implement, and evaluate the effectiveness of key LTSS strategic initiatives including trends, policies and programs, designed to drive the delivery of high value healthcare supporting a sustainable competitive business advantage for Aetna LTSS members.

This position will also lean heavily into the Medicaid cost reduction initiatives such as Scorable action items (SAI’S) and be responsible for leading the collaboration across the Medicaid markets to identify and implement cost reduction initiatives as well as playing a critical role in the development of vendor relationships and agreements (SOW)

In this role, the selected individual will Partner with internal stakeholders to advocate, promote and champion the vision and values that support our model of care;

identify cross-functional interdependencies and operational efficiencies in areas of Long term Care. In addition, this position will serve as a SME to all Medicaid LTSS RFP submissions and provide strategic guidance supporting initiatives across the national Medicaid LTSS line of business including but not limited to UM, Quality, care management, and network growth as listed below..

• Support the RFP and RFI processes in all LTSS markets with participation in meetings and SME revisions with proposal writers and provide guidance to or participate in including orals presentations
• Support NCQA recertification in all LTSS markets
• Actively participate in SAI activities to identify and appropriately convert eligible members to LTSS products
• Assure compliance with State contracted mandates for cost, quality, and care management initiatives.
• Provide clinical expertise and guidance in the development of State imposed Corrective Action Plans and drive successful timely closure of all CAPS.
• Provide clinical expertise and guidance on member rebalancing aligned to cost effective care delivery.
• Drive the implantation of NCQA templates for improving documentation to support successful auditing.
• Assess and redesign as needed LTSS dashboards specific to LTSS state contracts
• Serve as RFP / RFI / RFA LTSS SME input and participation for writing and orals.
• Collaborate with Care Management, quality, and population health t teams and others to drive comprehensive, innovative care solutions for LTSS members.
• Participate in SAI / MEU reviews with LTSS markets states to identify possible areas of improvement particularly with rate cell changes and transitions into community
• Provide clinical expertise and guidance for Quality focused initiatives as determined by the plan leadership for NCQA and audits.
• Lead the Medicaid markets national SAI ideation, development, and implementation.
• Assist in other market related initiatives and projects as required.
• Lend clinical guidance and subject matter expertise to the Med Affairs team, population health team, and support national and market based clinical initiatives including selected vendor agreements

Primary Job Duties & Responsibilities :

• Creating and implementing LTSS strategy including vision and goal setting, team growth, value capture, and operational excellence
• Providing LTSS expertise and influence across teams as well as externally to ensure aligned, cohesive progress across technology, marketing, and service operations
• Working closely with data analytics team and develops specific actions to manage LTSS related medical cost trends
• Develops benchmarks for LTSS clinical staff productivity.
• Standardizes UM practices, quality and financial goals across Medicaid
• Responds to LTSS RFP sections and review LTSS portions of state contracts.
• Works with trainers to develop and provide enterprise-wide teaching on Elder care diagnoses and treatment.
• Writes, refines, and approves LTSS Policies and Procedures for utilization and case management.
• Implements clinical practice guidelines and medical necessity review criteria.
• Tracks all clinical programs for LTSS quality compliance with NCQA and CMS.
• Participates in the recruitment, placement, and orientation of new medical directors.
• Ensures all LTSS programs and policies are in line with industry standards and best practices.
• Assists with new program implementation and supports the health plan in-source LTSS services as appropriate.
• Fosters collaboration works cohesively together within the health plan Chief Medical Officer and utilization management clinical staff to positively impact utilization trends and cost
• General essential functions include responsibility for oversight of medical directors to ensure appropriate and timely utilization management activities for day-to-day operations, i.

e. prior authorization, concurrent review, peer-to-peer and appeal reviews are efficient, accurate, and progressive

• Work with individual markets to ideate and bring forward new cost reduction initiatives.
• Partner with the national SAI team to develop, size, report, implement, and track approved initiatives
• Actively participate in population health workgroups and provide SME to the development of clinical content
• Provide clinical guidance to population health vendor agreements and SOW.

Education :

Board certification by the American Board of Medical specialties (IM, FP, specialty certification or training in Geriatrics highly preferred).

Current state medical license without restrictions.

Master's degree in business or related field, preferred but not required.

Required Experience and Skills :

• 3+ years in healthcare business management, managed care or health plan management
• 5+ years demonstrated staff management experience
• Excellent knowledge of health care industry. Preferred industry depth in a Medicare and / or Medicaid line of business
• Strategic thinking with proven ability to communicate a vision and drive results
• Knowledge of Medicaid managed care utilization management operations and healthcare management
• Excellent interpersonal communication skills : ability to influence in executive settings and provide constructive feedback
• Ability to optimize resources using excellent judgment, and an attitude that fosters teamwork and supports organizational goals
• Strong team player and team building skills
• Creative problem-solving skills
• Proficiency with Microsoft Office applications (Outlook, Word, Excel, PowerPoint)

Pay Range

The typical pay range for this role is :

$184,112.50 - $396,600.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.

The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

This position also includes an award target in the company’s equity award program.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.

The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.

The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits.

CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.

As for time off, Company employees enjoy Paid Time Off ( PTO ) or vacation pay, as well as paid holidays throughout the calendar year.

Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.