Presbyterian Healthcare Services

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at Presbyterian Healthcare Services

Posted: 2/4/2019
Job Status: Full Time
Job Reference #: 15734

Job Description

About Us

Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of eight hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state’s largest private employer with approximately 11,000 employees.


Presbyterian’s story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.


We are part of New Mexico’s history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.


Job Description 

* Medical Degree



Other information:
M.D. or D.O. degree, with board certification. Five years clinical practice experience, currently licensed to practice without restriction, with at least three years of experience in a managed care setting developing and implementing LTSS programs. Experience crafting, implementing, monitoring, and championing clinical practice guidelines and resource, utilization, and cost management initiatives. Coursework or formal training in business desirable (e.g. M.B.A. or M.P.H. degree, courses sponsored by ACPE, Presbyterian Executive Leadership Program at RO Anderson School). At least two years clinical experience caring for a geriatric population.


Responsible for ensuring that medical protocols and practice guidelines support and promote the Centennial Care LTSS program, conducts reviews of clinical cases and oversees benefit determinations. Responsible for providing leadership and direction for LTSS aspects of the Centennial Care Quality and Performance Improvement Programs.


Requires detailed knowledge of medical management principles, including utilization management, case management, retrospective and concurrent review, and prior authorization, in terms of theories and practices to serve as the resource or educator to other practitioners. Sound understanding of managed care environment. Experience with Medicaid and state programs. Familiarity with National Committee for Quality Assurance (NCQA) and with Health Plan Employer Data and Information Set (HEDIS) principles and requirements.
*Leadership of LTSS clinical policy and program development and of the initiation of clinical strategies to improve quality and deliver cost effective care for the LTSS population.
*Consultation to the Senior Medical Director Centennial Care and Vice President, Government Affairs, other Medical Directors, State leadership, and clinical directors/managers and as requested by the Senior Medical Director Centennial Care, consultation/participation on policy issues, organizational goals, vendor management, and other activities necessary/useful in improving access and quality of care.
*Management of the development of State and corporate LTSS clinical standards, best practice guidelines, and clinical policy to improve care.
*Management of the development and approval of LTSS clinical and contractual outcomes included in provider and vendor contracts or agreements.
*Clinical oversight and support of Centennial Care LTSS programs, including care coordination, to ensure optimal quality of care.
*Oversight of LTSS and other prior authorization, utilization management, and benefit administration.
*Collaborates with providers and external groups/associations on clinical policy relevant to Centennial Care LTSS programs.
*Collaborates with the Senior Medical Director Centennial Care and PHP Compliance to ensure the compliance of Centennial Care LTSS, including that of providers.
*Collaborates with Provider Network Management to assist in the establishment of the LTSS network.
*Clinical leadership through ongoing LTSS case reviews.
*Performs benefit determinations, review of complaints/grievances and appeals as necessary.
*Responsible for overseeing processes to manage the cost of care for LTSS population.
*Serves on the PHP Pharmacy and Therapeutics Committee and participates as an advisor in all pre-meeting planning with department staff.
*Participates in ongoing identification, design, and development of clinical practice guidelines/disease management programs, prevention and wellness initiatives, clinical Quality Improvement Activities (QIAs), incorporating both national standards and local physician input. Serves on PHP UR/QA Committee to assist in development of clinical practice guidelines.
*Implements medical protocols and practice guidelines to support program initiatives including but not limited to:
*Reduction in Preventable Hospital Admissions
*Discharge Planning
*Preventive Immunization
*Chronic Care Management : COPD, CHF, DM, Depression
*Management of Dementia
*Appropriate Nursing Facility utilization and step down
*Community reintegration
*Alcohol abuse treatment and prevention
*Abuse and Neglect Identification
*Assessment of New Medical Technology
*Health Promotion and Wellness Activities Performance
*Works with others to carry out guideline development, education of providers and evaluation of programs and systems with a specific focus on geriatric models of care.



Benefits are effective day-one (for .45 FTE and above) and include:

  • Competitive salaries<\>

  • Full medical, dental and vision insurance<\>

  • Flexible spending accounts (FSAs)<\>

  • Free wellness programs<\>

  • Paid time off (PTO)<\>

  • Retirement plans, including matching employer contributions<\>

  • Continuing education and career development opportunities<\>

  • Life insurance and short/long term disability programs<\><\>


    About New Mexico

    New Mexico’s unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich life>Santa Fe’s artists, and you get an eclectic mix of people, places and experiences that make this state great.


    Cities in New Mexico are continually ranked among the nation’s best places to work and live by Forbes magazine, Kiplinger’s Personal Finance, and other corporate and government relocation managers like Worldwide ERC.


    New Mexico offers endless recreational opportunities to explore, and enjoy an active life> 

    AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.








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