Senior Medical Director, Medicare – Value-Based Payment

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🗽 New York – Remote

🗽 New York – Remote

💵 $249.8k - $374.8k / year

⏰ Full Time

🟠 Senior

👨‍⚕️ Medical Director

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LTHC

WebsiteLinkedInAll Job Openings

2 - 10 employees

Founded 2016

🧘 Wellness

⚽ Sports

👥 B2C

Wellness • Sports • B2C

LTHC é a empresa que detém a Academia LIFT e pretende adquirir ou desenvolver outros espaços no mesmo âmbito. Foca‑se na experiência do cliente — conforto, interação com o espaço e objetivos pessoais — para atletas, praticantes ocasionais e profissionais, apoiando metas de bem‑estar físico, psicológico e desempenho competitivo. Opera como um espaço de fitness/treino com ênfase em culturismo, exercício e saúde.

📋 Description

• Serve as a senior clinical advisor to line of business leadership on strategy, population health, medical cost, quality, and regulatory priorities • Develop and execute clinical strategy aligned with organizational growth, quality, and financial objectives • Translate clinical, utilization, quality, and financial data into actionable strategies and operating priorities • Establish provider performance expectations, clinical benchmarks, scorecards, and improvement strategies • Provide clinical leadership for utilization management, prior authorization, concurrent review, case management, and care coordination • Optimize site of care and reduce avoidable inpatient admissions, readmissions, emergency department utilization, and unnecessary high-cost services • Improve preventive care, chronic disease management, medication adherence, member experience, and quality measures • Partner with Quality leadership on quality improvement strategies and monitor medical expense, PMPM trends, utilization, risk-adjusted performance, quality, and VBP results • Apply CMS, NYS, NCQA, federal regulatory, payment, and quality methodology knowledge • Perform appeals and case reviews on claims and pre-authorization requests • For Medicare LOB only, partner with Compliance, Legal, and Regulatory Affairs on initiatives and audits • Collaborate with line of business leadership, contracting, actuarial, finance, quality, pharmacy, analytics, care management, and operations • Maintain member privacy, integrity, attendance, and compliance with organizational values and policies • Perform other functions as assigned by management

🎯 Requirements

• Degree in medicine: M.D. or D.O. • Board certification required • Unrestricted active NYS Medical license required • Three (3) years of experience as a Medical Director for a health plan or equivalent experience required • Experience designing and supporting shared savings, shared risk, capitation, global risk, bundled payment, and other value-based arrangements in MA • Strong analytical and financial acumen • Demonstrable understanding of managed care and healthcare delivery structures • Working knowledge of CMS, NYS, and NCQA requirements, applicable federal regulations, and evolving payment and quality methodologies • For Medicare LOB only: at least 5 years of progressive leadership experience in Medicare Advantage, managed care, population health, health plan, ACO, provider organization, or comparable environment • Extensive Medicare Advantage experience • Expertise in Medicare Advantage and healthcare economics of risk-based populations • Strong understanding of Medicare risk adjustment, CMS-HCC methodology, clinical documentation, and RADV requirements • Ability to travel across the Health Plan service region • Valid Class D license and ability to operate a motor vehicle

🏖️ Benefits

• Group health and/or dental insurance • Retirement plan • Wellness program • Paid time away from work • Paid holidays • Potential remote work, determined case-by-case