The CMO is the senior physician leader in a WellCare Market. The main responsibilities will be to improve the quality and cost of care for the members in the markets. Specifically, they work directly or in a matrix to ensure all members receive quality healthcare as measured by HEDIS and STARS. Additionally, they work with shared services and market staff to facilitate the care continuum for their members. The physician leader is an integral member of the executive team, and reports to the market president. They will be part of provider relations activities, monitors and actively manages performance of participating physicians, and assists in the development and implementation of medical policy. The CMO is responsible for various market committees (i.e. Credentialing and UMAC). The CMO is ultimately responsible for activities that lead to NCQA certification in the market, clinical components of EQRO audits, and Medicare quality (STARS) where appropriate.
- In a matrixed environment, guides medical management and quality initiatives for assigned areas to include concurrent review for outlier LOS for financial accruals, Field Case Management, Quality Improvement & accreditation initiatives, Pharmacy utilization, quality and cost management of provider network, and program leadership for various corporate and local initiatives designed to improve member care and minimize unnecessary costs.
- Participates in all clinical review and quality activities as required by individual state Medicaid contracts.
- Interprets medical policy for associates to facilitate the healthcare needs of plan members.
- Works closely with P&L owners to develop strategies to change member and provider behavior to improve quality of care, while also reducing medical costs.
- Works closely with and influences key business partners within a matrix organization faced with competing priorities.
- Makes recommendations (based on daily activities of evaluating members' care) about medical policy, clinical criteria, and administrative process. Serves on market and enterprise work groups and committees as appropriate.
- Chairs UMAC, credentialing and related market health plan committees.
- Works with the medical community to assist in the development and maintenance of a strong, quality network of providers.
- Supports provider relations and risk contracting through education, provider visits and problem resolution.
- Represents WellCare at physician educational and networking meetings, local/regional/national as appropriate. Meets with physician groups when needed for recruitment, quality improvement, quality of care, etc.
- Works with quality management and medical cost analysis staff to identify trends in treatment and outcomes by interpreting various data.
- Reviews provider and member complaints, assist in resolution, and make recommendations for changes.
- Utilizes clinical expertise to assist in the development of care improvement programs to improve health outcomes for the member population.
- May manage and develop direct reports who include directors and/or senior managers.
Additional Responsibilities: Candidate Education:
- Required a Doctor in Medicine (MD) Or D.O. from an accredited school of medicine recognized by national medical regulatory bodies in the United States
- Required 5 years of experience in patient care and a strong working knowledge of managed health care
- Required other 3 years additional experience in the Payer sector at medical director level or higher.
- Required other substantial experience and expertise in the development, implementation, and execution of medical policies, procedures and programs
- Required other demonstrated success implementing utilization and quality improvement strategies /techniques and experience with physician behavior modification is required
- Required other qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to: Education, training or professional experience in medical or clinical practice
- Required Other Must have significant experience in NCQA certification, HEDIS and STARS programs, concurrent review and case management
- Required other demonstrated success in management/medical director roles in Payer or Integrated Delivery Systems, including implementing utilization tools/techniques.
- Preferred other past participation in hospital managed care or medical practice UM committee
- Preferred other experience working with Chief Executive Officer of organization (e.g., CEO's of Hospital systems, CMO's of IPA's, etc.)
Candidate Skills:Licenses and Certifications:
A license in one of the following is required:
- Required other board certification
- Required Other Current license without restrictions in working state or the ability to obtain that license.
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Excel