Horizon Blue Cross Blue Shield of New Jersey
Med Dir., Prov Perf & Clin Transf
This Medical Director role focuses on designing, developing, and delivering provider education and performance management initiatives to support the Quadruple Aim: improving patient and provider experience, population health, and affordability. The role involves cultivating relationships with stakeholders and providers to deliver customized analytic and evidence-based performance management solutions, refining strategies for provider engagement, and leading a team of clinical transformation and quality improvement specialists.
Key Responsibilities
- • Design curriculum for provider education including but not limited to value based clinical workflows, utilization reduction strategies, quality, member experience, health equity and disparities, and appropriate risk adjustment/ coding.
- • Develop provider education materials and approaches for providers at varying levels of readiness to transform.
- • Collaborate with internal and external SMEs (e.g. other medical Directors, quality and risk adjustment teams, and others) to receive relevant materials, insights, and strategies to be incorporated.
- • Partner with SIG and their many work-streams to ensure learnings and strategy are incorporated.
- • Research and incorporate global, national, and state based leading evidence based practices.
- • Use output of Voice of Provider surveys and Population health surveys to inform this work.
- • Create provider transformation evaluation process for benchmark and interval evaluation.
- • Identify and refine key KPIs, in collaboration with enterprise partners, to incorporate into partner facing initiatives that will drive change in our VBP and FFS partner portfolio.
- • Research forward-thinking transformation practice models and programs for incorporation into partner playbooks to improve performance.
- • Partner with network facilities and providers to develop and implement initiatives that drive quality, manage cost and improve performance.
- • Establish multidisciplinary teams for partner transformation engagement, for example, with transformation coach interactions, clinical collaboration calls, special KPI projects, etc.
- • Serve as physician SME for projects related to transformation and Health Care Value across the enterprise, such as Clinical Performance Measurement & Predictive Analytics, Strategic Initiatives Group, Medical Economics and Risk Adjustment, etc.
- • Design, update, implement, and review biannual value-based partner population health surveys.
- • Train value-based team on the interpretation of clinical insights reports and the message delivery to partners.
- • Research, design, update, and implement value based quality program for each program year.
Required
- • Requires an Medical Doctor (MD) or Doctor of Osteopathy (DO) degree.
- • Requires a minimum of 10 years clinical experience in patient centric/value based setting, NCQA certification preferred.
- • Requires a minimum of 5 years of medical management experience in a managed care setting.
- • Requires physician leadership experience in integrated delivery systems with financial accountability.
- • Requires experience with management of physicians and non-physicians.
- • Current unrestricted Medical Doctor (MD) or Doctor of Osteopathy (DO) license from the state of New Jersey.
- • Principles of population health and value based care.
- • Principles of Utilization Management, URAC, NCQA UM Standards, and peer review.
- • State and federal regulations i.e. DOBI, DMAHS, CMS.
- • Principles and concepts of managed care and various models of health care delivery systems.
- • Principles and concepts of managed care operations, policies, and reimbursement.
- • Business of medical practice management.
- • Broad clinical knowledge and understanding of current health care issues.
- • Strong clinical acumen to support understanding broad physical health issues, behavioral health issues, and social determinants of health.
- • Medical literature analysis.
- • Interpretation and application of medical policy to provide guidance to others.
- • Excellent verbal, written, and presentation skills.
- • Expertise in the delivery of highly technical information to a general audience.
- • Personal computer, applicable software.
- • Virtual communication platforms.
- • Balance clinical issues with business imperatives and directives in the context of social responsibility.
- • Evaluate data from various sources to identify trends and issues.
- • Demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
- • Manage multiple priorities, deliver timely and accurate work products with a customer service focus.
- • Ability to exercise sound judgment with strong problem solving skills.
- • Manage physicians and employee staff.
- • Build alliances with provider community and have insight into the mindset of practicing physicians in NJ.
- • Foster internal cross organizational collaborations to support project design and delivery.
Preferred
- • NCQA certification preferred.
Benefits & Perks
- • Comprehensive health benefits (Medical/Dental/Vision)
- • Retirement Plans
- • Generous PTO
- • Incentive Plans
- • Wellness Programs
- • Paid Volunteer Time Off
- • Tuition Reimbursement
Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
About The Role
This Medical Director role is responsible for designing, developing, and delivering provider education and performance management initiatives to support the Quadruple Aim: improve the patient and provider experience, improve population health, and improve affordability. The Medical Director will cultivate relationships with internal and external stakeholders and key providers to ensure the delivery of customized analytic and evidence based performance management solutions that support quality outcomes and value based care goals. The position will refine and devise strategy for provider and partner engagement to increase collaboration, improve care management, and encourage care delivery innovation. The Medical Director will lead a team of clinical transformation and quality improvement specialists.
Responsibilities
What You'll Do
What You Bring
Clinical
At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!
Salary Range
$214,100 - $297,885
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
About The Role
This Medical Director role is responsible for designing, developing, and delivering provider education and performance management initiatives to support the Quadruple Aim: improve the patient and provider experience, improve population health, and improve affordability. The Medical Director will cultivate relationships with internal and external stakeholders and key providers to ensure the delivery of customized analytic and evidence based performance management solutions that support quality outcomes and value based care goals. The position will refine and devise strategy for provider and partner engagement to increase collaboration, improve care management, and encourage care delivery innovation. The Medical Director will lead a team of clinical transformation and quality improvement specialists.
Responsibilities
What You'll Do
- Design curriculum for provider education including but not limited to value based clinical workflows, utilization reduction strategies, quality, member experience, health equity and disparities, and appropriate risk adjustment/ coding.
- Develop provider education materials and approaches for providers at varying levels of readiness to transform:
- Collaborate with internal and external SMEs (e.g. other medical Directors, quality and risk adjustment teams, and others) to receive relevant materials, insights, and strategies to be incorporated
- Partner with SIG and their many work-streams to ensure learnings and strategy are incorporated
- Research and incorporate global, national, and state based leading evidence based practices
- Use output of Voice of Provider surveys and Population health surveys to inform this work
- Create provider transformation evaluation process for benchmark and interval evaluation.
- Identify and refine key KPIs, in collaboration with enterprise partners, to incorporate into partner facing initiatives that will drive change in our VBP and FFS partner portfolio.
- Research forward-thinking transformation practice models and programs for incorporation into partner playbooks to improve performance.
- Partner with network facilities and providers to develop and implement initiatives that drive quality, manage cost and improve performance
- Establish multidisciplinary teams for partner transformation engagement, for example, with transformation coach interactions, clinical collaboration calls, special KPI projects, etc.
- Serve as physician SME for projects related to transformation and Health Care Value across the enterprise, such as Clinical Performance Measurement & Predictive Analytics, Strategic Initiatives Group, Medical Economics and Risk Adjustment, etc.
- Design, update, implement, and review biannual value-based partner population health surveys.
- Train value-based team on the interpretation of clinical insights reports and the message delivery to partners.
- Research, design, update, and implement value based quality program for each program year.
What You Bring
- Requires an Medical Doctor (MD) or Doctor of Osteopathy (DO) degree.
- Requires a minimum of 10 years clinical experience in patient centric/value based setting, NCQA certification preferred.
- Requires a minimum of 5 years of medical management experience in a managed care setting.
- Requires physician leadership experience in integrated delivery systems with financial accountability.
- Requires experience with management of physicians and non-physicians.
- Current unrestricted Medical Doctor (MD) or Doctor of Osteopathy (DO) license from the state of New Jersey
- Principles of population health and value based care.
- Principles of Utilization Management, URAC, NCQA UM Standards, and peer review.
- State and federal regulations i.e. DOBI, DMAHS, CMS.
- Principles and concepts of managed care and various models of health care delivery systems.
- Principles and concepts of managed care operations, policies, and reimbursement.
- Business of medical practice management.
- Broad clinical knowledge and understanding of current health care issues
Clinical
- Strong clinical acumen to support understanding broad physical health issues, behavioral health issues, and social determinants of health.
- Medical literature analysis.
- Interpretation and application of medical policy to provide guidance to others.
- Excellent verbal, written, and presentation skills.
- Expertise in the delivery of highly technical information to a general audience.
- Personal computer, applicable software.
- Virtual communication platforms.
- Balance clinical issues with business imperatives and directives in the context of social responsibility.
- Evaluate data from various sources to identify trends and issues.
- Demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
- Manage multiple priorities, deliver timely and accurate work products with a customer service focus.
- Ability to exercise sound judgment with strong problem solving skills.
- Manage physicians and employee staff.
- Build alliances with provider community and have insight into the mindset of practicing physicians in NJ.
- Foster internal cross organizational collaborations to support project design and delivery.
At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!
Salary Range
$214,100 - $297,885
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
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