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The Community Plan of Virginia Chief Medical Officer (CMO) will use their proven track record to become the end-to-end owner of the clinical programs for Virginia Community & State. The position has accountability for all Medicaid clinical product offerings, clinical market strategies, clinical support for sales and growth opportunities, collaboration and engagement with our Shared Services clinical team, clinical data analysis to improve clinical and cost outcomes, new clinical program implementations, monitoring and valuing clinical outcomes and operational performance, driving affordability pipeline and performance, overseeing development and implementation of initiatives to meet quality standards, ensuring compliance with state Medicaid compliance standards-where applicable, and appropriate capital stewardship.
If you live in Virginia, you will have the flexibility to work remotely* as you take on some tough challenges.
Primary Responsibilities:
- Develop solid collaborative partnerships across a highly complex and matrixed organization including key partnerships with the local Market leadership team, functional VPs, Market CMOs, health plan CEOs, and Executive Directors across all lines of business (Commercial, Medicare, Medicaid).
- Oversight of clinical processes and policy decisions with a focus on implementing plans of care that meet accepted guidelines and protocols to ensure that optimal and appropriate medical & clinical services are provided.
- Drive improved affordability related to medical and pharmacy spend for lower TCOC, greater capture of state level quality-based incentive dollars, and improved provider diagnosis, documentation and capture of member chronic conditions.
- Ensure services are delivered to members at the highest quality standards. Oversee and ensure development and implementation of initiatives to meet or exceed HEDIS quality standards, and accreditation standards through working with and holding Quality Shared Services accountable.
- Continuously improve HEDIS and CAHPS scores for members and providers.
- Provide guidance and direction to physicians and nurses regarding all aspects of medical care and multi-level transitions of care including the referral process as well as any quality-of-care concern and related plans of correction.
- Review inpatient cases where applicable for successful bed-day management that meets established company goals.
- Analyze utilization data to identify trends and opportunities for process improvement related to medical treatment (inpatient and outpatient).
- Serve as clinical subject matter expert for needs assessment, design, implementation, and evaluation of clinical programs to support continued growth and affordability of the Health Plan.
- Participate in senior medical management strategy development and implementation to ensure that appropriate care and services provided to members meet best practice standards as well as regulatory compliance requirements and Internal Quality Assurance Program.
- Educate physicians and nurses in effective management of Health Plan benefits and medical services that meet the needs of the members and utilize resources appropriately.
- Knowledge and proficiency in applying Virginia Med-QUEST division rules and regulations.
- Development, implementation, and oversight of the population health strategy to include health equity and cultural competency.
- Oversee provider recruitment and credentialing.
- Serve as co-chairman of the Health Plan’s Utilization Management and Quality Assurance Plan committee.
- Oversee the development and revision of the Health Plan’s clinical care standards and practice guidelines and protocols.
- Ensure coordination of Out-of-Network services.
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles