Associate Chief Medical Officer

About the role

The Associate Chief Medical Officer is an executive level physician leader and a visible medical spokesperson for Horizon Blue Cross Blue Shield. This position has accountability for medical policy and/or medical review, appeals determinations, utilization management, clinical development of medical cost reduction initiatives, collaboration with care management program to optimize patient outcomes and participation and retention standards for all provider networks.

Responsibilities

• Set clinical strategy in line with the overall company vision and continually monitors Horizon BCBSNJ's utilization policies to ensure the company stays current with changing local and national trends;
• Accountable for the development of procedures and guidelines that will be used to monitor the specialized clinical services provided to members and establishes standards of care which identify desirable, observable characteristics of care based on current practice guidelines;
• Responsible for working with medical management and cross functional teams to develop and implement clinical innovations to improve efficiencies and partnerships with providers;
• Using metrics and data analytics, conducts root/cause analysis to measure goal achievement and identify issues or trends that need remediation;
• Responsible for development of clinical strategy;
• Implements Horizon BCBS medical cost reduction initiatives to achieve targeted savings and offset trends;
• Responsible for the identification of, contracting with and oversight of Delegated Vendors;
• Identify MCAP opportunities;
• Ensures compliance with regulatory entities (DOBI, NCQA, DMAHS, and CMS) and may serves as clinical contact for regulators;
• Serves as a spokesperson for the organization, focusing on quality healthcare delivery, providing leadership for clinical thinking for the company;
• Ensures review of medical records for medical necessity and appropriateness of care and ensures high quality, ethical clinical review procedures;
• Builds a strong knowledge base of the providers in New Jersey while strengthening productive relationships and identifying areas for improvement; be recognized as a thought leader within the organization, the provider community, consumers and other key stakeholders in regards to clinical quality;
• PARTNERS WITH PROVIDERS TO SUCCESSFULLY IMPLEMENT NEW PROGRAMS AIMED AT INCREASING CLINICAL QUALITY AND EFFECTIVENESS;
• Maintains effective communication strategies with key external stakeholders and executive leadership of key external partners;
• Serves as liaison and represents Horizon BCBS NJ in contacts with internal and external stakeholder, and Governmental agencies;
• PARTNERS WITH THE VICE PRESIDENTS FOR NETWORK AND WITH THE VP AND CHIEF CLINICAL TRANSFORMATION OFFICER, TO HELP SHAPE CLINICAL QUALITY AND PERFORMANCE FOR PROVIDERS WITHIN THE HORIZON NETWORK AND ENFORCE CLINICAL QUALITY MEASURES AND GUIDELINES;
• HELPS SHAPE CLINICAL QUALITY FOR NEW FORMS OF PARTNERSHIPS WITH HOSPITALS AND PROVIDERS;
• WORKS CLOSER WITH NETWORK STAFF TO DEVELOP HIGH-QUALITY PHYSICIAN NETWORKS; DEVELOPS AND IMPLEMENTS A PLAN TO REMEDIATE NETWORK PRACTITIONERS WHO DEMONSTRATE ABERRANT PRACTICE PATTERNS AND QUALITY OF CARE;
• SERVES AS A RESOURCE FOR MEDICAL DIRECTORS IN THE REVIEW OF CASES REFERRED BY UTILIZATION MANAGEMENT STAFF AND AS A RESOURCE FOR VARIOUS OTHER HEALTH SERVICES PROGRAMS;
• IDENTIFIES AND MITIGATES RISKS TO THE ENTERPRISE;
• Regional Care Management, as applicable
• Directs and manages operations and performance of programs in Regional Care Model;
• Provides clinical direction and leadership to promote continuous quality improvement within enterprise clinical operations;
• ACCOUNTABLE FOR MEDICAL MANAGEMENT PERFORMANCE, FOR SHORT TERM AND LONG TERM STRATEGIC GOALS;
• PROVIDES ADEQUATE SUPPORT FOR CARE MANAGEMENT TEAM TO ENSURE THAT CARE MANAGEMENT PERFORMANCE GUARANTEES ARE MET;
• ENSURES OVERALL CLIENT SATISFACTION (INCLUDING SELF-INSURED ACCOUNTS) AND APPROPRIATE LEVEL OF SERVICE DELIVERY;
• PLAYS A LEAD ROLE IN INTEGRATION OF BEHAVIORAL AND PHYSICAL HEALTH;
• ENSURES/SUPPORTS THE ADOPTION OF THE LATEST MEDICAL POLICIES AND CLINICAL GUIDELINES THROUGH THE HORIZON BCBSNJ ORGANIZATION AND/OR STRIVES FOR CONSISTENCY WITH NATIONAL STANDARDIZED PRACTICE AND INDEPENDENT REVIEW ORGANIZATIONS (IRO AND IURO).

Qualifications

• Absolutely current unrestricted license to practice medicine (MD or DO).
• Board certification in an accepted medical specialty a plus or evidence of candidate remaining current with medical knowledge (e.g. up to date with NJ State CME requirements).
• A minimum of 10 years clinical experience.
• A minimum of 7 years of experience with medical management in a leadership role.
• Experience working within a large, multi-level organization either within a health plan or provider organization.
• Demonstrated success in implementing managed care policies, programs or initiatives.

Skills and Abilities

• Excellent understanding of the principles and concepts of managed care.
• Broad knowledge of utilization management and patient appeals process.
• Broad clinical knowledge and understanding of current health care issues and industry trends.