Chief Clinical Officer

Key Responsibilities

• Develop and implement the clinical strategy for the I-SNP, aligning with organizational goals and financial sustainability.
• Serve as the clinical subject matter expert to the CEO, Board of Directors, and executive leadership team.
• Drive innovation in care delivery models, risk adjustment optimization, and affordability initiatives tailored to the needs of institutionalized members.
• Oversee care management, utilization management, and interdisciplinary care team programs to improve health outcomes and control costs.
• Ensure timely and accurate completion of HRAs and ongoing documentation to support comprehensive risk adjustment.
• Collaborate with network providers and facility partners to optimize care quality and reduce unnecessary utilization, including avoidable hospitalizations and emergency visits.
• Monitor provider performance, clinical outcomes, and total cost of care, implementing corrective actions and improvement initiatives.
• Lead clinical risk adjustment strategy, ensuring complete and accurate coding and documentation of members’ conditions.
• Partner with finance to align clinical programs with revenue optimization and compliance requirements.
• Develop and oversee affordability strategies, including medical cost management, value-based care initiatives, and collaborate with pharmacy on drug utilization oversight.
• Ensure care models balance high-quality outcomes with sustainable financial performance for the plan.
• Drive quality improvement initiatives to achieve CMS Star Ratings, HEDIS, CAHPS, and other key benchmarks.
• Ensure compliance with all CMS regulations, NCQA standards, and state requirements governing SNPs.
• Co-Chair the Quality Improvement Committee and other clinical governance bodies.
• Oversee population health programs focused on identifying and managing high-risk, high-cost members.
• Champion member experience by ensuring care is goal-directed, culturally competent, and person-centered.
• Build strong partnerships with providers and facilities, offering education and support on risk adjustment, affordability, and quality measures.
• Engage providers in value-based arrangements to align incentives with quality and cost outcomes.
• Lead, mentor, and develop clinical staff, including nurse practitioners, care managers, and medical directors.
• Promote a culture of accountability, compliance, and continuous improvement.
• Ensure clinical teams understand and contribute to risk adjustment and affordability strategies.

Qualifications

• An MD, DO, NP, or PA with an active, unrestricted license; board certification preferred.
• A minimum of 10 years of clinical leadership experience, with at least 5 in managed care, Medicare Advantage, or long-term care.
• Demonstrated expertise in I-SNP, Special Needs Plans, or institutional care models strongly preferred.
• A strong knowledge of CMS Medicare Advantage regulations, risk adjustment (HCC coding, RAF scores), affordability strategies, and quality programs.
• A proven ability to manage medical costs while improving member outcomes and satisfaction.
• Data-driven leader with experience using analytics to drive clinical and financial performance.
• Exceptional leadership, communication, and relationship-building skills.