The Medical Director for Pediatrics is a physician executive who shall report to the CMO Tufts Health Public Plans, but have direct accountability to the Director of Medical Affairs for enterprise transactional work; supporting the Commercial, Public Plans and Senior Products divisions. This role involves four (4) predominant scopes of work, described below:
- Physician Leadership
- Pediatric Care Management program development & Consultation
- External Relations representation- Government, Policy and Industry Advocacy organizations (like MCAAP & MVPAC) and network provider engagement
- Utilization Management, non-UM transactional work and other General Medical Director responsibilities
He/she will perform utilization management functions for all Tufts Health Plan products and member s, including but not limited to Commercial, Senior Products and Public Plans. These functions will include prospective, concurrent and retrospective utilization review, including appeals and grievances; working closely with staff from all partner UM and Medical Management Departments. In addition s/he may perform retrospective provider claims payment disputes, medical record reviews for potential quality of care issues, appropriateness of care and DRG validation and re-admission reviews including bridging cases. In addition he/she will provide physician leadership for all pediatric programs, including Care Management and Quality Assurance functions, within Tufts Health Public Plans. He/she will help support the Pediatrics network across all regions and all products for all Tufts Health Public Plans.
Utilization Management, non-UM transactional work and General Medical Director responsibilities
- Performs clinical review of prospective, concurrent, and retrospective coverage requests for in-patient and out-patient services requiring prior authorization and medical review
- Communicates with providers, provider groups, facilities, and others as necessary to resolve clinical issues and concerns during Peer-to Peer reconsideration process
- Performs clinical review of expedited and standard appeals
- Participates in inter-rater reliability exercises
- Serves as pediatric physician SME for UM cases, working to train and educate other medical directors and physician UM reviewers on pediatric clinical issues.
- Performs provider claims payment disputes, retrospective claims' audits, case reviews of medical records for potential quality of care issues, appropriateness of care and DRG validation and readmission reviews including bridging cases.
- Participates in staff meetings, trainings and other meetings as required
- Provides physician leadership in THPP ACOs for interactions with pediatric providers including but not limited to Boston Children's Hospital/CHICO and their affiliated physician groups.
- Provides pediatric physician expertise regarding growth, development and maintenance of pediatric BH network, services and clinical programs
- Advises THP IMPAC and Med Tech Committee regarding Pediatric medical or behavioral health benefit and medical necessity policy decisions
- Provides pediatric physician leadership in assessing and promoting quality care by all network providers, working with the clinical Quality Improvement and Quality Measurement Departments as well as THPP Network Contracting particularly with risk contracts such as designated facilities
- Serves as pediatric SME on pediatric clinical programs and projects, including working with the THPP Medical Trend Management office to analyze and mitigate unfavorable trends
- Participates in meetings and committees as requested
Pediatric Care Management Leadership & Consultation Responsibilities (in partnership with the VP Care Management THPP)
- Provides THPP physician leadership for the oversight & provider interactions of the THPP ACO's pediatric Care Management programs.
- Provides thought leadership, pediatric clinical expertise and member advocacy in care management rounds and for individual cases, including ICM
- Serves as physician leader to develop and revise pediatric clinical care management programs
- Is readily accessible for consultation with care managers and other care management staff
- Assists care managers and utilization managers in identifying and implementing alternative services as appropriate to an individual member's plan of care
- Serves as the physician provider liaison for the care management teams, communicating/meeting with clinical decision makers in the provider community and when appropriate meeting with individual members and convening inter-agency case conferences to develop, approve and implement plans of care for individual pediatric members
- Participates in and when appropriate leads the development, implementation and monitoring of CMS, Medicaid and individual state required pediatric clinical quality improvement projects
- Supports the Pharmacy operations team with analysis, development and maintenance of pediatric pharmacology policies and procedures.
External Relations Responsibilities (in partnership with the CMO THPP, VP Provider Relations THPP and VP Product THPP)
- Works in partnership with the VP Provider Relations THPP to develop and maintain collaborative functioning relationships with key providers, particularly thought leaders, across the Tufts Health Public Plans delivery footprint
- Assists and supports the THPP Network Contracting teams in the development and implementation of single case agreements needed to address the clinical needs of uniquely situated members
- Assists and supports the THPP Network Contracting and Finance teams, an as appropriate, enterprise Fraud Prevention and Recovery teams in identifying and remediating billing and performance issues involving individual providers, groups and facilities
- Participates in and when appropriate leads the development, implementation and monitoring of provider-facing initiatives and projects
- Participates in meetings with THPP network pediatric providers regarding pediatric criteria, policies, care management and clinical programs.
- In partnership with the THPP VP Product, develops appropriate relationships with EOHHS staff and represents THPP at relevant EOHHS and other regulatory agency meetings and professional societies as needed concerning policies and procedures
- Provides physician support of pediatric QA activities
- Discusses cases as needed with inpatient and/or outpatient pediatric providers
- Participates in meetings and committees as requested
A little about us:
Founded in 1979, Tufts Health Plan is nationally recognized for its commitment to providing innovative, high-quality health care coverage.