The Medical Director – Centennial Care will join an established team that is shaping the future of Presbyterian’s Medicaid plan and the evolution of the State of New Mexico’s Medicaid program.
Presbyterian Health Plan – Presbyterian Healthcare Services’ insurance entity – includes Medicaid and Medicare insurance plans, as well as multiple commercial options. The Medicaid plan – Presbyterian Centennial Care – currently serves more than 300,000 of New Mexico’s Medicaid members. New Mexico named the program “Centennial Care” in 2012 to honor one hundred years of statehood.
The scale and diversity of the Medicaid population affords unusual opportunities to effect change. Presbyterian leadership work one-on-one with New Mexico HSD personnel who are very open to initiatives, pilot programs, etc. that align with Centennial Care goals.
The following list highlights the opportunities this position offers for professional, cultural, and personal growth:
- Play an integral role within a fully integrated healthcare system.
- Break new ground in medical cost management and population health management.
- Support development and revisions to Medical Policies.
- Assist in initiatives to ensure accessibility of quality, affordable care and coverage for PHPs customers and members.
- Provide clinical leadership and promote best practices across the Presbyterian organization.
- Manage relationships with providers across the state.
- Support population health efforts, including a large population of vulnerable individuals in achieving their best health.
- Support New Mexico in improving the health of its population.
- Provide guidance and support for forward-thinking quality improvement initiatives.
The Centennial Care Medical Director reports to the Presbyterian Health Plan (PHP) Senior Medical Director. S/he will be primarily responsible for performing medical necessity determinations in partnership with PHPs Utilization Management. The Medical Director is responsible for ensuring medical protocols and practice guidelines. This includes utilization management of health care services primarily with the prior authorization staff, participation in formulating complex care coordination, as well as peer-to-peer discussions with community clinicians. The Medical Director will also provide medical oversight, expertise, and leadership to ensure the delivery of cost-effective, quality healthcare services PHP members.
- Leads ongoing identification, design, and development of clinical practice guidelines/disease management pathways, incorporating both national standards and local physician input.
- Provides leadership in the education of members, providers, and PHS entities in the principles of coordination of care and utilization/resource/cost management, particularly as this relates to PHP.
- Primary responsibility for and direction of PHP utilization management activities, including direction and support for nurses in prior authorization, concurrent and retrospective review, referral coordination, and case management activities.
- Maintains effective liaison with provider groups in order to foster open communication and engender a collegial atmosphere in working toward a common goal: quality, cost effective health care.
- Assists in identifying and addressing examples of inordinate variation in patterns of utilization, and guiding staff and providers to effective resolution.
- Participates in development and implementation of an outcomes-oriented PHP Quality Management Program.
- Assists in the development of strategic plans for addressing resource management concerns and opportunities.
- Supports Delegated Groups through collegial educational efforts and facilitation of communication with these groups.
- Monitors and assists in the implementation of a quality, cost effective pharmacy program.
- Participates in all appropriate committee activities within the Quality committee structure.
- Participates in relevant strategic and benefit planning sessions.
- Insures compliance with HCFA, HSD, DOI and all other regulatory agencies.
- Supports PHP in achieving and maintaining NCQA, HCFA, IPRO and all other accrediting requirements.
- Helps to ensure the implementation of an effective information system which is relevant in measuring both quality and utilization outcomes.
- Supports efforts of PHP in developing and distributing a severity-adjusted Physician Practice Profile.
- Supports PHS-wide Health management activities designed to improve the health of those individuals, families, and communities we serve.
- Performs other functions as required.
- M.D. or D.O. degree, with board certification
- Five years of clinical practice experience
- Currently licensed to practice without restriction
- Experience in a managed care setting strongly preferred
- Experience in use of application of evidence-based clinical practice guidelines and resource, utilization, and cost management initiatives.
- Requires detailed knowledge of medical management principles, including utilization management, case management, retrospective and concurrent review, and prior authorization, in terms of theories and practices both directly and to serve as the resource or educator to other practitioners.
- Understanding of managed care environment.
Experience with Medicare, Medicaid and state programs desirable. Familiarity with National Committee for Quality Assurance (NCQA) and with Health Plan Employer Data and Information Set (HEDIS) principles and requirements desirable.
Benefits are effective day-one (for .45 FTE and above) and include:
- Competitive salaries
- Full medical, dental and vision insurance
- Flexible spending accounts (FSAs)
- Free wellness programs
- Paid time off (PTO)
- Retirement plans, including matching employer contributions
- Continuing education and career development opportunities
- Life insurance and short/long term disability programs
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state’s largest private employer with approximately 14,000 employees.
Presbyterian’s story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.
We are part of New Mexico’s history – and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
About New Mexico
New Mexico’s unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque’s International Balloon Fiesta, Los Alamos’ nuclear scientists, Roswell’s visitors from outer space, and Santa Fe’s artists, and you get an eclectic mix of people, places and experiences that make this state great.
Cities in New Mexico are continually ranked among the nation’s best places to work and live by Forbes magazine, Kiplinger’s Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it’s all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses
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