CMO, Utilization Management and Medical Policy

Purpose:
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 medical leadership in the clinical and quality strategies and operations for the ISD's medical management, including oversight of all physician utilization management and medical policy teams. This position will also serve as the lead physician for all commercial products. In addition, this position will engage whenever indicated with IDFS clinical partners and will be the clinical leader in our provider benchmarking activities.This position will oversee the management of physicians, will collaborate with other clinical leadership to insure the development, implementation and appropriate coverage of effective services, will serve as the authority on medical issues and is responsible for compliance with all clinical medical policies, directives, rules, regulations and clinical performance standards related to the identified lines of business, including all relevant accreditation and state and federal government regulations and all accrediting bodies for all lines of business, under the direction of the CMO. This senior leader is accountable for ensuring the membership receives exceptional service and that clinical outcomes meet or exceed all standards or benchmarks. He/she assures best standards of practice and promotes person centered, recovery-focused care models and policies within the division working with internal and external stakeholders to represent an integrated approach to health. This leader also promotes cost-effective practice patterns through appropriate interventions with health care providers while meeting or exceeding the expectations of internal and external customers by utilizing first-hand member and scientific data for continual improvements for products and services. This position will directly interact with physicians, hospitals, and physician practices.

Responsibilities:
 

• Contribute clinical and operational expertise to Division CMO, CEO and all senior management activities at the Insurance Services Division.
• Manage the development, implementation, and provision of ongoing clinical evaluation of the lines of business as assigned.
• Oversee the development, implementation and ongoing evaluation of clinical resource management programs and community-based programs. 
• Oversee the standardization of practice patterns and the achievement of desired outcomes through clinical resource management and provider benchmarking.
• Oversee and supervise the Medical Policy team to insure timely, evidence-based, data-driven development and implementation of appropriate medical policies, both pre-service and post-service, to ensure the members receive coverage for clinically appropriate services in the most cost effective level of care.
• Oversee the physician Medical Director team to ensure compliance with all regulatory requirements, appropriate interpretation of medical policies, consistent implementation of utilization management criteria across all lines and collaboration across the IDFS as well as other network and non-network facilities.
• Provide support of the provider relations activity of the lines of business as assigned. Supervise and guide the Medical Directors in identified lines of business in regards to meeting and exceeding standards or benchmarks for quality care and establish benchmarks or standards as needed.
• Represent UPMC Insurance Services Division at various internal and external meetings/conferences. 
• Develop and cultivate strong working relationships with regulatory entities.
• Participate in the strategic planning of the UPMC Insurance Services Division. 
• Exemplify a collaborative approach to work ethic for staff to model.
• Establish and monitor the appropriate budget as assigned. Select, retain, develop, and reward a competent staff.
• Develop strategies to foster external relationships (including state and federal agencies) 
• Recommend annual plan along with the strategies, tactics and resources necessary to achieve division goals and objectives directly related to the essential functions of the position.