A managed care organization.
The Chief Medical Officer (CMO) reports to the Chief Executive Officer and leads the clinical, medical services, and quality management teams.
Serving as a senior executive and member of the leadership team, the CMO is responsible for providing clinical leadership and working cooperatively and effectively with the CEO and senior leadership team, utilizing a balanced and collaborative approach to ensure the achievement of annual business and strategic goals and objectives. The CMO is responsible for setting clinical strategic goals and direction, clinical policy, and providing oversight of policy and program implementation, including continuous quality improvement activities. He/she provides expert medical advice and guidance to business units and relevant stakeholders. Substantial involvement is required in the Quality Improvement/Performance Improvement program functions including credentialing, utilization review, and monitoring of subcontractors. The individual oversees and is responsible for all clinical activities, including but not limited to the proper provision of covered services to members and recipients, developing clinical practice standards, clinical policies and procedures, utilization management, pharmacy, population health and care management, and quality management. The individual is responsible for ensuring an integrated approach to the physical and behavioral health of members and recipients, including those with I/DD and TBI needs.
Specific duties include, but are not necessarily limited to:
- Strategic Clinical and Business Planning – Assist the CEO with development of clinical strategic planning including adoption of new clinical technologies, advocating with regulators around needs for contract changes to allow for clinical innovation, and seeking out and developing new clinical lines of business. Develop a clinical vision, mission and approach that introduces innovative ways to provide solutions and drive actionable impact through an executable approach.
- Clinical Analytics – Provide key clinical leadership in developing clinical analytics in partnership with IT/Data Science.
- Accreditation – Partner with appropriate business units to ensure national accreditation is maintained.
- Clinical Accountability – Chair the Continuous Quality Improvement Committee and ensure quality improvement activities are appropriate and successful. Partner with Quality Management to broadly monitor contractual compliance and to strategize ways to improve clinical performance on key performance indicators.
- Stakeholder Relationships – Represent the company and manage high profile, strategic clinical relationships including Community Care of North Carolina (CCNC), hospitals, elected and other state officials, and clinical business partnerships.
- Utilization Management Plan Implementation – Direct the development of a utilization management plan and program which monitors authorized services to ensure consumers receive medically necessary care as indicated and are moved to higher or lower levels of care as needed. Ensure consistency and integrity through formal procedures and clinical protocols that are developed in accordance with best practices, within state and federal requirements, and medical necessity. Ensure that there are written UM procedures in accordance with the UM Plan that comply with all applicable state and federal laws, rules, and regulations for each level of care that are consistent with practice guidelines.
- Care Management Activities – Ensure consumer utilization of services, as related to identified needs, is monitored. Ensure follow-up is provided on high risk cases to encourage involvement in treatment prior to deterioration or development of crisis situations; follow up after institutional or hospital discharge.
- Medicaid Appeals – Ensure that the requests for services are not arbitrarily denied or reduced in amount, duration, or scope.
- Adverse Incidents and Sentinel Events – Provide oversight to the management of incidents and high risk cases to ensure these are evaluated for severity, trends, use of coercive interventions, as well as indicators for health and safety risks, abuse, neglect, or rights violations. Develop strategies to reduce risk related to adverse events identified from data trends.
- Practice Guidelines – Ensure clinical practice guidelines reflect evidence-based and consensus-based practices and are focused on achieving outcomes of self-determination, independence, and recovery.
- Qualification of Providers – Responsible for credentialing/qualifying providers to ensure qualified and competent providers are enrolled in the closed provider network and every enrollee has adequate access to high quality care.
- Quality Management – Oversee the Quality Department and ensure operational performance, provider measurement (HEDIS), and clinical quality is measured and achieved.
- Experience with public community behavioral health services and consumers with developmental behavioral disabilities, serious behavioral illness, co-occurring behavioral illness and substance abuse, and children who are emotionally disturbed.
- Wide knowledge of medical, pharmacological, and service-related support needs of these populations; ability to make decisions about need for care and provide consultation and advice to other community physicians.
- Able to work collaboratively and effectively with other team members to develop processes and protocols, analyze data, and solve problems.
- Able to establish positive relationships with both the medical community and other key stakeholders.
- Self-directed, able to organize and prioritize work, obtain and access needed information, interpret complex written materials, and able to discriminate between essential and non-essential tasks.
- Experience with overseeing departments and work teams of the agency.
- Managed care and community behavioral health experience, or experience with Medicaid and other publicly served population strongly preferred.
- Minimum of five years’ experience in a health clinical setting and five years’ experience in managed care.
- At least five years of experience working as an executive physician in a key leadership role.
- Completion of medical school and completion of a residency.
- Must be a primary care physician or psychiatrist, fully licensed to practice in North Carolina and in good standing.
- If primary care physician, clinical experience with child/adolescent and adult populations is preferred. (If individual does not have experience with all populations, direct medical staff reports must have experience).
- If a psychiatrist, clinical experience with child behavioral health or addiction/SUD is preferred. (If individual does not have child behavioral health or addiction/SUD experience, direct medical staff reports must have experience).
- Must reside in North Carolina.
Compensation will be commensurate with experience including a competitive base salary, bonus opportunity, and competitive benefits package.