Job Description

Summary Description:

The Chief Medical Officer (CMO) is responsible for all areas of Medical Management including, but not exclusive to, Utilization Management, Quality Management, Credentialing, Medical Policy Development, and Medical Informatics. The CMO will provide leadership, management and direction for all medical management operations, reporting and contracting functions while ensuring that the Board of Directors, Chief Executive Officer (CEO), the President, and other members of the senior leadership team have constant access and timely updates relative to departmental information and analysis necessary to assist in meeting its operational goals and business objectives as set forth in the company’s strategy for growth and annual performance budget. This position carries out responsibilities in the following functional areas: Chair Quality Committee, Chair Appeals Review Meeting, Chair Peer Review Committee, Member Pharmacy Oversight Committee, Utilization Management and Quality Management meetings, ensuring compliance with requirements for confidentiality and conflict of interest, development of staff relationships, and bringing together the coalition of Medical Groups and Integrated Delivery Systems. The CMO also serves as the Chief Health Equity Officer for the plan with responsibility to ensure health equity across plan services.

Representative Duties:

• Promote and adhere to WHA’s Privacy and Information Security Programs. Ensure and verify that all department Workforce Members attend and complete mandatory training. Inform department Workforce Members that WHA will take disciplinary action up to and including termination of employment or assignment with WHA for violation of these privacy and security policies, procedures, and regulatory requirements. Also, that strict adherence to the related laws, rules, regulations, policies, and procedures is considered an integral part of their job performance and monitor compliance.

• Contribute to the strategic direction, goals and vision of the plans offered by Western Health Advantage.
• Provide UM coverage approximately 2 days a week for cases related to but not limited to Appeals & Grievances, Investigational/Experimental and out of Area admission reviews. ​​​​​​
• Provide clinical oversight to the Medical Management staff and remain ultimately responsible for the Utilization Management Program and the oversight of any delegated functions.
• Responsible for maintaining Compliance with all California and Federal laws and regulations as applicable.
• Responsible for developing and executing the Medical Management budget.
• Responsible for the overall quality of care program to include (but not limited to) performance review, Credentialing, Clinical Program Development, Quality Outcomes, Disease State Management, Out of Area Repatriation, Clinical Programs Management
• Develop and interpret medical policy guidelines from nationally recognized entitles, governmental, or internally developed.
• Responsible for required reporting to all WHA clients, including but not limited to, CalPERS, Covered CA, Federal Employees Health Benefits program and Employers.
• Develop data driven strategies to manage high cost / high utilizing members and effectively engage members in WHA clinical programs to improve clinical outcomes and bend Total Cost of Care.
• Responsible for oversight of all clinical aspects of the grievance/appeal system and for continuous review of appeal, complaint, and grievance data to identify emerging patterns of member dissatisfaction.
• Report on work of the Quality Improvement Committee (QIC) to the Board of Directors.
• Lead and drive efforts on Provider Integration with WHA’s Medical Groups and Hospital Partners including but not limited to Access, Quality, Cost Management and other areas as directed by CEO/President.
• Responsible for supporting and growing relationships with WHA Brokers and Employer clients
• Actively participate in WHA Board meetings, providing reports and input when directed.
• Assist and oversee clinical regulatory and accreditation audits.
• Monitor network access and recommend actions to WHA and delegated Medical Groups as.
• Establish and implement the departmental staffing plans and sound business processes to support the effective execution of the company’s business plans and strategies.
• Work collaboratively with Human Resources and Medical Management Department Team leaders to select, train, supervise, and effectively performance manage the medical management staff.
• Maintain consistently high-performance standards for all departmental staff and team members by regularly communicating business updates, coaching, counseling, disciplining and completing timely performance evaluations in accordance with the company’s HR guidelines and standards.
• Establish and execute personal and professional development initiatives for the Medical Management Department team members and their self for the purpose of keeping current and effective in the performance of their various job duties and roles.
• Perform other duties and special projects as assigned.
• Avoid and report all potential and actual conflicts that may arise in course of CMO duties per WHA’s applicable policies on Conflict and Excess Benefit Transactions.

Skills:

• Highly proficient at strategic planning and building effective company business that are directly linked to the achievement of the company’s business performance objectives.
• Has a highly proficient understanding of Federal and State and commercial regulations as dictated by both the Department of Health Services and the Department of Managed Health Care while working closely with the Chief Executive Officer as they interact with the State of California regulatory agencies and other payers.
• Possesses a working knowledge of capitation, medical risk, and HMO contracting including the role utilization plays in affecting the bottom line of the business.
• Possesses a full understanding of the company’s Business Plan envisioning multiple payers set against a complex web of federal and State regulations and policies.
• Proficient in business relevant software programs used within the Medical Management department including, Excel, Word, Outlook and Salesforce software.
• Effective public speaking, group presentations and one-on-one interactions, both internal and external to the company with a proven ability to positively influence listeners, which includes use of communications aids (i.e. charts, graphs, overheads, etc.).
• Proficient with leadership practices and processes with members of their medical management department, including administration and adherence to company policies and procedures.
• Highly effective at building rapport that encourages trust, inspires confidence and enlists cooperation with all other WHA team members and departments in a variety of work situations.
• Highly proficient at establishing credibility and maintaining effective work relationships with those contracted in the performance of required duties for the company.
• Highly proficient with oral and written communication in the primary language(s) used in the workplace, including the ability to prepare reports and business correspondence in a professional and timely manner.

Qualifications:

• Doctorate in Medicine or Osteopathy.

• 7 years’ clinical management experience.

• Current License to practice medicine without restriction in the State of California required.

• Must be California State Board Certified.

• Highly competent computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc. Specifically, the ability to create formulas and graphs in Excel and import them into Word documents.

• Must be able to speak, read, write, and understand the primary language(s) used in the workplace.

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Salary : $350,000.00 - $380,000.00 Annually + up to 30% bonus opportunity

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.

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