Director, Medical Policy

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health .

Job Summary

The Director, Medical Policy has responsibility for leading the organization’s enterprise Medical Policy department activities. The Director leads, directs and modifies business processes and operations ensuring compliance with Point32Health business rules and develops, implements, and refines systems and processes to ensure compliance with all relevant regulatory and accrediting requirements for these functional areas. The Director will demonstrate subject matter expertise in the areas of medical technology assessment and medical policy development and implementation for the organization. She/he ensures that initiatives are on schedule and within budget, and guides strategy, policies, and protocols in accordance with organizational goals. He/she is responsible to identify and oversee the analysis and implementation of process changes to improve administrative efficiencies and optimize results and value for his/her teams’ work. The Director directs teams to achieve objectives. He/she leads cross departmental and cross company initiatives, and may represent Point32Health to outside organizations, vendors and agencies related to these functions.
The Director is responsible for oversight of clinical and non-clinical teams to achieve these objectives. He/she may represent the Vice President Medical Affairs to internal stakeholders, external organizations and state agencies on issues related to, medical technology, and policy and must balance a personal workload as well as supervisory responsibilitiesThe Director demonstrates the ability to make strategic/complex recommendations that reflect consideration of its impact to a broad stakeholder group, the enterprise, the three divisions and the company at large. The Director, Medical Policy can take on complicated tasks that require advanced analytic, assessment and evaluation skills and possesses strong inter-personal and leadership skills. Effective stakeholder management is a critical function of a director.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Medical Policy

• Responsible for all initiatives, project teams and committees that support the Enterprise-Wide Medical Technology and Medical Policy team and processes.

• Ensures that appropriate key performance and outcomes measures are in place and utilized for medical policy program assessment and management. Actively monitors and manages quality standards through the interpretation of data and metrics.

• Leads inter-departmental projects to maximize efficiency of resources, ensure application of regulatory requirements and ensure consistency of medical policy implementation and oversight of for our products.

• Provides support to organizational project teams that require medical policy staff participation.

• Directs all existing and manages the evaluation of new requirements impacting medical policy development for all existing and futures lines of business and new acquisitions, identifying gaps and risks and developing and implementing strategies and processes to mitigate risks and gaps and ensure compliance with these requirements considering business needs.

• Leads inter-departmental projects to maximize efficiency of resources, promote consistency of application of regulatory requirements and ensure consistency of medical policies for all lines of business, as appropriate.

• Ensures appropriate department documentation and structure to support reliable departmental and interdepartmental performance and functionality

• Continually evaluates opportunities to support organizational effectiveness and priorities and marshalls dedicated work efforts to reach corporate goals and objectives

• Regulatory and Compliance

• Manages the implementation of changes required, as a result of changes in state and federal regulatory, EOHHS (Executive Office of Health and Human Services), NCQA (National Committee for Quality Assurance) accreditation or CMS requirements across the enterprise which impact Medical Policy work for all lines of business.

• Works with the government affairs and legal teams to evaluate and make recommendations regarding the impact of new regulations and legislation related to the clinical quality and medical Policy department work.

• Ensures department readiness to meet audit requirements related to any line of business

• Staff and Resource Management

• Mentors, supervises, and trains staff to ensure each is working at his/her potential, is encouraged to develop professionally, and fosters cross training and supports adequate depth of skill mastery for successful achievement of business and professional goals.

• Leads department wide employee engagement activities and initiatives

• Responsible for team budget process, realization of department administrative budget targets and for maintaining cost effective staffing levels in collaboration with Vice President, Quality Management Develops a plan for training and developing a succession plan for key team roles

• Other projects and duties as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

• Valid Registered Nurse licensure

Education

• Required (minimum): Bachelor’s degree

• Preferred: Master’s degree or equivalent work experience in healthcare administration and/or relevant field

Experience

• Required (minimum): 10-12 years of experience in medical policy, utilization management or quality improvement or relevant work within a managed care or provider environment. Significant experience managing clinical and non-clinical staff, leading significant cross-functional high-level initiatives, directly managing business process change and working within a matrixed organization. 5 years of managerial experience.

• Preferred: Project management experience preferred

Skill Requirements

• Proven ability to achieve goals, deliver “bottom line” results, successfully lead people and work at all levels of an organization to achieve the intended results

• Proficiency in computer use, specifically PC-based systems including advanced word processing, database management and spreadsheets. Requires excellent written, oral communication and presentation skills, including experience in business writing, such as project proposals and descriptions. Project management experience preferred

• Excellent organizational skills and ability to successfully manage multiple priorities and tasks simultaneously.

• Attention to detail and the ability to accomplish smaller critical tasks of projects while maintaining a thorough understanding of the project’s larger impact on other departments, as well as implications for the company and provider network.

• The ability to establish short and long-term goals that will achieve the needs of the company; must be able to establish realistic timelines and follow-through to meet those goals within the established time parameters

• Key Competencies:

• Results orientation - dr