Risk Adjustment Medical Director Albuquerque New Mexico

Optum - New Mexico
Albuquerque, New Mexico
Jul 23, 2020
Jul 23, 2021
General Practice
Full Time
Position Type

The Medical Director will partner with the CMO in directing the clinical strategy in the market to support and enable Independent Practice Affiliate Physician Offices of Optum to enhance the delivery of care in a value based population health care environment.

This individual will work to build strong, trusted relationships with other clinicians to influence and change behavior in a collaborative way. The Medical Director will be required to work cross-functionally and will be expected to provide insight and perspective from the network point of view to the CMO and leadership team. They will work with the CMO with utilization management (UM), prior authorization determinations, oversight and direction of inpatient and skilled nursing facility utilization, oversight and direction of Outpatient Care Management Services, Medicare Risk Adjustment Factor (RAF) education as well as HEDIS/STARS education, and provider/group relationship building. This individual will be meeting with clinicians in the care delivery setting and will work with them and the CMO to identify opportunity for improvement in clinical documentation, coding and effective utilization. Frequent travel within the metropolitan area is expected.

Leadership Competencies:

  • Business Acumen: Uses economic, financial, market, and industry data to understand and improve business results; uses one s understanding of major business functions, industry trends, and own organization s position to contribute to effective business strategies and tactics.
  • Leadership: Demonstrates the traits, inclinations, and dispositions that characterize successful leaders; exhibits behavior styles that meet the demands of the leader role. Identifies goals for site or department in consultation with other Medical Directors and Operations leadership; leads efforts by providers and teammates to achieve those goals
  • Building Trust: Interacts with others in a way that gives them confidence in one s intentions and those of the organization.
  • Facilitating Change: Encourages others to seek opportunities for different and innovative approaches to addressing problems and opportunities; facilitates the implementation and acceptance of change within the workplace. Encourages others to participate in creating a positive culture of the Clinic and the Medical Group and to uphold the Mission, Vision and live the Core Values.
  • Managing Conflict: Deals effectively with others in an antagonistic situation; uses appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
  • Building Strategic Work Relationships: Develops and uses collaborative relationships to facilitate the accomplishment of work goals.

Essential Functions:

  • Strategic leadership over the Independent Practice Affiliate Program in New Mexico
  • Working on best practices, policies, telehealth and novel approaches for risk adjustment programs
  • Apply understanding of patient care quality metrics to enhance clinical outcomes (e.g., HEDIS; 5 STAR; disease-based metrics) in order to drive/achieve quality outcomes for Optum NM s Affiliate Program
  • Lead efforts for RAF/HEDIS/STARS education to improve metrics and outcomes for the Affiliate Program
  • Effectively engaging and bringing understanding to our external constituents such as physicians, medical and specialty societies, hospitals and hospital associations, and state regulators
  • Identifying affordability opportunities through participation in local medical expense committees or market reviews
  • Provide assistance in appeals review where appropriate
  • Supporting all clinical quality initiatives and peer review processes


  • Required: Fully licensed as a physician in the state of New Mexico.
  • Preferred: Master s Degree in related filed


  • Required: Two (2) years experience at senior leadership level in medical group or network; Five (5) years experience as a practicing physician preferably in a medical group.
  • Preferred: Experience in both fee-for-service and managed care operations. Experience and knowledge of Medicare Advantage programs (STARS, RAF, HEDIS, CHAPS/HOS etc). Experience with identifying Medicare risk adjustment and presenting findings to client/clinicians

Knowledge, Skills, Abilities:

Thorough understanding of medical group business models and clinical processes.

Ability to strategically lead regionally to ensure accurate diagnostic codes in order to maximize risk adjustment (RAF).

Experience with identifying Medicare risk adjustment and presenting findings to client/clinicians; Working knowledge of managed care and value based medicine

Excellent understanding of medical group financial concepts, including revenue cycle, physician compensation models, and preferably including managed care financial concepts (capitation, IBNR, MLR).

Helping set agendas/strategies and leading multifaceted teams of Physician Business Managers, Risk Adjustment dyads, and Quality partners.

Licensure: Required:

  • Current MD/DO unrestricted medical license in the state of New Mexico Board Certified or in the process of obtaining certification unless granted an exemption by Credentialing Committee.
  • New Mexico Pharmacy/DEA Registration if applicable to practice.
  • Current BLS Certification

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work.(SM)

Diversity creates a healthier atmosphere: Optum and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Optum and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

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