Director, Medical Policy

About the role

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