Chief Medical Officer

Chief Medical/Health Officer

This position is responsible for setting and achieving goals in collaboration with the Executive Leadership Team and direction of the CEO and Board, relating to the delivery of high quality accessible, and equitable managed care services. The CMO is the primary representative for the organization to all external stakeholders for matters relating to health services and programs. The CMO is the clinical spokesperson for the organization for health policy matters with State and other regional networks and coalitions relating to provision of healthcare services.

Accountable for oversight of medical criteria, policies and procedures relating to utilization and care management, delegated health care services, management of pharmacy services (including PBM), quality and clinical performance improvement programs, including programs to advance health equity, and NCQA-accreditation requirements.

Responsibilities

• Provide organizational leadership for the organization as an active participant on the Executive Leadership Team (ELT) in setting organization direction, strategies, priorities, and policies, and in working with leadership and staff throughout the organization.


• Keep abreast of emerging models in health care delivery; identifies innovative strategies to meet the needs of members and providers.


• Build and leverage cross functional collaborative relationships to achieve shared company goals.


• Lead innovative and population-based programs around health care improvement and population health initiatives.


• Ensure organization is well-equipped to support integration of physical, behavioral, social and other services for whole-person care model.


• Provide clinical leadership on value-based reimbursement and value-based purchasing programs.


• Develop and lead strategic goals related to the quality improvement, costs management, accreditation standards and health equity.


• Provide strategic direction and oversight for a comprehensive Quality program that supports the highest performance of Plan network providers and ensures high quality outcomes and member/patient satisfaction across all regions and products.


• In collaboration with CHNW Leadership and the Board Quality Committee, oversee a comprehensive quality program for Community Health Network of Washington (CHNW), consistent with its mission and the values of the partner member centers, and supportive of the quality program goals of the organization.


• Chair the Quality Council and leadership support to the Quality Committee of the Board of Directors.


• Responsible for the oversight of the organizations NCQA accreditation process and successful outcomes, as well as the ongoing organizational commitment and readiness to maintain and improve quality standards as defined by NCQA and the Health Care Authority (HCA) and CMS.


• Lead efforts to obtain highest STARS rankings for Medicare products and highest quality rankings for Medicaid and other lines of business.


• Ensure the development and implementation of quality monitoring, reporting, analysis and improvement systems and that functional measures are linked to organizational goals. Keeps up-to-date on industry trends and benchmarks.


• Collaborate across the Plan and Network in the development of quality measures for new payment models (value based/risk-based payment structures).


• Serve as the principal liaison to the organization for providers, and as the primary physician resource for community health centers (CHCs) and affiliates for activities related to expansion of clinical practice methods, sharing of best clinical and process improvement practices, integration of new models of care, and quality improvement.


• Engage active participation by the Community Health Centers (CHC) and other key providers in clinical performance improvement activities and medical management, including opportunities for improving access, cost and quality of care in their communities.


• Lead the CHNW Medical Director Roundtable and identifies and supports other learning collaborative opportunities with providers and CHCs.


• Forge and retain strong relationships and continuing communication links with clinic medical directors and provider groups.


• Oversee delegated health care services, pharmacy management and quality programs and ensures full compliance with regulatory and contractual requirements.


• Oversee development of clear medical management policies, procedures, guidelines and services.


• Work with division management, ensuring effective day-to-day supervision of the preparation, effective hiring, appropriate performance management and development of staff, with the goal of developing a cohesive, empowered, and productive work force.


• Oversee quality of care reviews and complaints ensuring timely and appropriate resolution for impacted members and providers.


• Oversee concurrent and retrospective medical claims review programs, ensuring that care is consistently meeting acceptable levels of quality standards.


• Approve appropriate medical policy recommendations that guide utilization management decisions and meet regulatory and quality standards.


• Participate in retrospective review of paid claims, admission authorization, grievances, and other sources where policy, utilization, or quality issues are involved. Recommend intervention strategies or programs as appropriate.

Education and Qualifications

Medical Degree (MD or DO) from an accredited college or university required

• Additional business-related degrees or training preferred

License, Certifications, and other Specialized Training

• Current, unrestricted license in the State of Washington as an MD or DO required


• Certification through the American Board of Medical Specialties required


• Certification through the American Board of Medical Specialties in a primary care specialty preferred

Experience

• A minimum of five (5) years of medical management experience in a managed care plan or delegated medical group, preferably working with state sponsored programs, required


• Minimum of five (5) years as a medical director or officer in a health plan, preferably in managed care working with state sponsored programs, preferred


• Minimum of five (5) years clinical practice required


• Experience with Medicaid populations required and experience with Medicare populations preferred


• Experience with community or migrant health centers desired


• Experience with social drivers of health, behavioral health and community- based services, as part of an integrated model, preferred


• Experience working with and using clinical data to improve efficiency and effectiveness of care. Experience with quality improvement principles and models, especially HEDIS


• Experience with National Committee on Quality Assurance (NCQA) accreditation process and standards required


• Familiarity with programmatic and clinical research strategies in a managed care setting preferred

Knowledge, Skills, and Abilities

• Passion for improving the health and well-being of populations and communities who have been historically underserved. Experience working with low-income, underrepresented populations to improve health outcomes.


• Ability to inspire others to serve and work towards system change.


• Proven effective leadership skills and demonstrated ability in organizing and inspiring individuals toward pursuit of a common vision and goal


• Demonstrated ability to identify systemic issues to promote real change


• Expertise with performance improvement principles and methods, systems thinking and how processes are linked.


• Experience developing and managing high-level plans and strategies, with ability to work at a detailed level.


• Experience with the various components of managed care (quality improvement, disease management, population management, utilization management, case management and pharmacy management).


• Highly skilled and knowledgeable in the development and implementation of health care policy, particularly in the areas of quality, medical appropriateness, and utilization of health care services and health equity.


• Demonstrated high proficiency and expertise in clinical work and cost-effective health care.


• Knowledge of federal and state health care programs


• Knowledge of Medicare programs


• Knowledge of regulatory requirements and their impact on the organization (for example, HEDIS, CAHPS, and NCQA)

This job description is designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties and responsibilities required of employees assigned to this job.

Our client is an Equal Opportunity Employer and does not discriminate based on race, religion, gender, age, sexuality, or gender identification.