Chief Medical Officer (MD or DO) - Health Plan
Your Job Summary:
The Chief Medical Officer (CMO) is responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent responsive medical care. The CMO is a critical medical and business leader and contact for external providers, plan sponsors, and regulatory agencies and participates in the strategic medical management. They provide medical leadership to ensure excellent quality of care and service is provided to our members and clients that are efficient and cost effective.
Formal education including a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree.
Must hold an active unrestricted license to practice medicine in that state.
Prefer a Master's degree in business, healthcare administration, or related field (MBA/MHA/MPH/etc).
Board Certified in a medical specialty recognized by the American Board of Medical Specialists (ABMS).
Prefer certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management.
At least 7-10 years clinical experience practicing medicine, with at least 5 years in an administrative capacity.
Around 3-5 years’ experience working for a Managed Care Organization (Health Plan/IPA/HMO/TPA/etc).
Substantial knowledge of mental health and chemical dependency services and practices, including a broad band of treatment techniques, procedures, and discharge planning.
Excellent written and verbal communication skills; and strong critical thinking, deductive reasoning and decision making skills are needed.
Ability to implement complex programs and to monitor implementation and modifications.
Provides direction and oversight to medical directors in a large health plan. Partners with medical management to increase effectiveness of medical management programs and promotes integration of other internal medical programs. Provides technical expertise in medical management by direct decision making in the areas of: pre-authorization, concurrent review of hospitalized patients, discharge planning, complex case and chronic care management, and credentialing. Oversees the clinical aspects of the quality management, credentialing, pharmacy, and medical management program. Leverages the use of predictive modeling and medical cost forecasting capabilities to improve decision making relative to cost spending. Chairs or staffs all peer-review committees such as Quality Improvement, Pharmacy and Therapeutics, Credentialing, and others that are deemed appropriate for the health plan; may participate in the Physicians Advisory Committee. Takes part in periodic consultations and conversations with peers and practitioners in the field. Analyzes medical cost drivers and develops specific plans to reduce excessive cost. Works with senior leadership to develop strategic approaches to improve company performance and expand growth by optimizing provider network, evaluating provider (hospital, physician, ancillary) contracts, and developing other creative approaches.
Works with the health plan CEO to develop strategic approaches to improve company performance and expand growth by optimizing the provider network, evaluating provider contracts, and developing other creative approaches. Provides oversight for all quality improvement projects and all accreditation activities (URAC / NCQA). Ensures a staff of qualified clinicians accountable to the organization for decisions affecting consumers is maintained, and that appeals are reviewed by non-subordinate board certified specialists. Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions. Works collaboratively with other functional areas that interface with medical management including provider relations.