Chief Medical Officer - Health Plan
for section headings like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We must include sections only when posting has real specific content. We have content for: Summary (maybe "About the role"?), Responsibilities (the job description includes many responsibilities), Requirements/Qualifications (education, certifications, experience), Skills (maybe leadership skills), Benefits (listed), Pay (not mentioned), Schedule (Work Arrangement remote/hybrid details). The instruction: "Prefer a few substantive sections over many thin ones." So we can combine some.
We must not repeat job title as heading. No Job ID. Remove boilerplate like AA/EOE etc.
We need to preserve all substantive info.
We need to use - for any list of duties/requirements/benefits, and
for prose.
We need to include sections only when posting has real specific content. So we can have sections: About the role (summary), Responsibilities, Requirements, Benefits, Work Arrangement (maybe as Schedule? but schedule is about remote/hybrid). Since schedule not explicitly given but work arrangement details could go under Schedule section. The instruction: Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we can use those exact headings if content exists.
We have content for About the role (summary). Responsibilities (the detailed duties). Requirements (education, certifications, experience). Qualifications maybe similar to Requirements; we could combine. Skills (leadership, communication, etc). Benefits (listed). Schedule (Work Arrangement). Pay not present, so omit.
We must not create sections with filler like "commensurate with experience". Not needed.
We need to preserve all substantive info: location address, work arrangement details, summary, responsibilities bullet points, medical policy etc, qualifications, preferred, benefits, about us, about New Mexico? The "About Us" and "About New Mexico" maybe considered boilerplate? It's descriptive about employer; could be considered substantive? The instruction: Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. "About Us" and "About New Mexico" might be considered company description; not explicitly excluded. Might keep as part of About the role? But we already have About the role section for summary; we could add a paragraph about employer under About the role or maybe a separate section? Not listed as allowed headings; but we could incorporate into About the role as prose.
We need to not repeat job title. So no heading for Chief Medical Officer.
We'll produce HTML:
About the role
Location: 9521 San Mateo NE Albuquerque, NM 87113-2237. Summary: The Chief Medical Officer is the senior physician executive responsible for the health plan’s clinical leadership, medical policy, clinical strategy, utilization management decision authority, medical necessity oversight, appeals, peer-to-peer review, and provider clinical engagement.... (rest of summary).
But we need to preserve all substantive info; we can't summarize away detail. So we need to include the full summary text as given. The summary paragraph: "The Chief Medical Officer is the senior physician executive responsible for the health plan’s clinical leadership, medical policy, clinical strategy, utilization management decision authority, medical necessity oversight, appeals, peer-to-peer review, and provider clinical engagement. In the refreshed model, the CMO should hold explicit accountability for UM decision responsibility, including medical necessity determinations, adverse determinations, clinical escalation, appeals, peer-to-peer review, and governance of medical criteria. The CMO should not be positioned as the primary operator of all UM and CM workflows. Those should sit with the Healthcare Value Leader. This is consistent with external health plan CMO benchmarking, where the CMO provides leadership for care management and utilization management programs, oversees appropriateness and medical necessity, develops clinical practice guidelines, leads medical cost/utilization analysis, and directs medical management decisions."
We'll put that in a .
Then Responsibilities: we have several bullet-like paragraphs: Senior Clinical Leadership, Utilization Management Decision Responsibility, Medical Policy and Clinical Criteria, Clinical Oversight of Care Management, Medical Cost and Utilization Leadership, Provider and Physician Engagement, Quality, Risk Adjustment, and Behavioral Health Partnership, Additional Job Description (Other Information). We could turn each bold heading into a
- with the prose inside.
We need to preserve all substantive info, so we need to include each responsibility paragraph as list items.
We'll create
Responsibilities
- Senior Clinical Leadership: ... (the whole paragraph)
... etc.
Similarly for Requirements: we have Required MD or DO..., Active unrestricted medical license – New Mexico, Board certification, 10+ years..., Managed care..., Experience with..., Strong physician leadership..., etc. We'll list each as - .
Preferred: list as
- items.
Skills: maybe we can extract from Required: Strong physician leadership, executive communication, business acumen, and influence skills. Also maybe from Preferred: advanced degree etc. We'll put skills in a
.
Benefits: list as .
Schedule (Work Arrangement): we have Remote: Open to applicants in the United States, excluding CA, IL, ND, NY, OH, WA, and WY. Hybrid: For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday. We'll put as or
. Probably .
We also have About Us and About New Mexico; we could incorporate into About the role as additional paragraphs after summary, or maybe a separate section "About the organization". Not in allowed headings but we could still include as
under About the role. The instruction: Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It doesn't forbid other headings, but says use those for section headings. Safer to stick to those headings and put extra info under About the role.
Thus About the role will contain location address, summary, and maybe About Us and About New Mexico paragraphs.
We must not repeat job title as heading; fine.
We must not include boilerplate like AA/EOE etc. Remove that line.
Now produce HTML fragment.
Let's craft.
We'll need to escape any HTML special characters? Not needed.
We'll produce:
About the role
Location Address: 9521 San Mateo NE Albuquerque, NM 87113-2237
The Chief Medical Officer is the senior physician executive responsible for the health plan’s clinical leadership, medical policy, clinical strategy, utilization management decision authority, medical necessity oversight, appeals, peer-to-peer review, and provider clinical engagement. In the refreshed model, the CMO should hold explicit accountability for UM decision responsibility, including medical necessity determinations, adverse determinations, clinical escalation, appeals, peer-to-peer review, and governance of medical criteria. The CMO should not be positioned as the primary operator of all UM and CM workflows. Those should sit with the Healthcare Value Leader. This is consistent with external health plan CMO benchmarking, where the CMO provides leadership for care management and utilization management programs, oversees appropriateness and medical necessity, develops clinical practice guidelines, leads medical cost/utilization analysis, and directs medical management decisions.
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees. Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans. We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great. Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC. New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
Then Responsibilities:
Responsibilities
- Senior Clinical Leadership: Serve as the senior physician executive for the health plan. Lead all Medical Directors and UM staff members including clinicians, and other clinical staff reviewers. Provide clinical leadership across affordability, quality, utilization, access, member outcomes, population health, and provider engagement. Advise executive leadership on clinical risk, utilization trends, medical cost drivers, medical policy, provider behavior, and quality improvement opportunities. Represent the health plan in physician, provider, regulatory, and delivery system forums.
- Utilization Management Decision Responsibility: Serve as the accountable clinical leader for UM medical necessity decision-making. Oversee adverse determinations, peer-to-peer review, appeals, reconsiderations, clinical escalation pathways, and physician reviewer consistency. Ensure UM decisions are evidence-based, timely, fair, well-documented, and aligned with applicable federal, state, accreditation, and plan requirements. Maintain clinical oversight of criteria, medical necessity rationale, denial language, decision consistency, and reviewer performance. Partner with the Healthcare Value Leader to ensure UM operations support timely and compliant clinical decisions. NCQA’s UM framework emphasizes objective, evidence-based criteria, relevant clinical information, qualified professionals, fair and timely decisions, and appropriate appeals handling.
- Medical Policy and Clinical Criteria: Own clinical governance for medical policies, clinical criteria, practice guidelines, and evidence-based care standards. Ensure policies are current, clinically appropriate, compliant, and operationally implementable. Partner with Compliance, Legal, Quality, Pharmacy, UM Operations, Network, and the Healthcare Value Leader on policy updates and implementation. Provide clinical leadership for coverage policy interpretation, new technology review, and emerging clinical practice changes.
- Clinical Oversight of Care Management: Provide clinical guidance for complex case management, disease management, transitions of care, high-risk member programs, and population health initiatives. Support the clinical design of care management programs while the Healthcare Value Leader owns operational execution. Participate in complex case escalation, avoidable utilization review, post-acute strategy, and clinical intervention design. Collaborate with CM Operations to ensure programs are clinically sound and focused on the right populations.
- Medical Cost and Utilization Leadership: Partner with the Healthcare Value Leader, Finance, Actuarial, Analytics, and Network to review medical cost and utilization trends. Provide physician leadership on initiatives related to inpatient utilization, ED utilization, post-acute care, specialty variation, site-of-care optimization, pharmacy trends, and avoidable admissions. Support development of clinical interventions that reduce unnecessary utilization while preserving access and quality. External CMO benchmarking includes accountability for leading medical cost and utilization analysis and correcting identified or anticipated utilization issues while assuring members receive needed care.
- Provider and Physician Engagement: Serve as the health plan’s senior clinical representative to physicians, provider groups, and delivery system leaders. Lead physician-to-physician
for prose. We need to include sections only when posting has real specific content. So we can have sections: About the role (summary), Responsibilities, Requirements, Benefits, Work Arrangement (maybe as Schedule? but schedule is about remote/hybrid). Since schedule not explicitly given but work arrangement details could go under Schedule section. The instruction: Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we can use those exact headings if content exists.
We have content for About the role (summary). Responsibilities (the detailed duties). Requirements (education, certifications, experience). Qualifications maybe similar to Requirements; we could combine. Skills (leadership, communication, etc). Benefits (listed). Schedule (Work Arrangement). Pay not present, so omit.
We must not create sections with filler like "commensurate with experience". Not needed.
We need to preserve all substantive info: location address, work arrangement details, summary, responsibilities bullet points, medical policy etc, qualifications, preferred, benefits, about us, about New Mexico? The "About Us" and "About New Mexico" maybe considered boilerplate? It's descriptive about employer; could be considered substantive? The instruction: Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. "About Us" and "About New Mexico" might be considered company description; not explicitly excluded. Might keep as part of About the role? But we already have About the role section for summary; we could add a paragraph about employer under About the role or maybe a separate section? Not listed as allowed headings; but we could incorporate into About the role as prose.
We need to not repeat job title. So no heading for Chief Medical Officer.
We'll produce HTML:
About the role
Location: 9521 San Mateo NE Albuquerque, NM 87113-2237. Summary: The Chief Medical Officer is the senior physician executive responsible for the health plan’s clinical leadership, medical policy, clinical strategy, utilization management decision authority, medical necessity oversight, appeals, peer-to-peer review, and provider clinical engagement.... (rest of summary).
But we need to preserve all substantive info; we can't summarize away detail. So we need to include the full summary text as given. The summary paragraph: "The Chief Medical Officer is the senior physician executive responsible for the health plan’s clinical leadership, medical policy, clinical strategy, utilization management decision authority, medical necessity oversight, appeals, peer-to-peer review, and provider clinical engagement. In the refreshed model, the CMO should hold explicit accountability for UM decision responsibility, including medical necessity determinations, adverse determinations, clinical escalation, appeals, peer-to-peer review, and governance of medical criteria. The CMO should not be positioned as the primary operator of all UM and CM workflows. Those should sit with the Healthcare Value Leader. This is consistent with external health plan CMO benchmarking, where the CMO provides leadership for care management and utilization management programs, oversees appropriateness and medical necessity, develops clinical practice guidelines, leads medical cost/utilization analysis, and directs medical management decisions." We'll put that in a. Then Responsibilities: we have several bullet-like paragraphs: Senior Clinical Leadership, Utilization Management Decision Responsibility, Medical Policy and Clinical Criteria, Clinical Oversight of Care Management, Medical Cost and Utilization Leadership, Provider and Physician Engagement, Quality, Risk Adjustment, and Behavioral Health Partnership, Additional Job Description (Other Information). We could turn each bold heading into a
- with the prose inside.
We need to preserve all substantive info, so we need to include each responsibility paragraph as list items.
We'll create
Responsibilities
- Senior Clinical Leadership: ... (the whole paragraph) ... etc. Similarly for Requirements: we have Required MD or DO..., Active unrestricted medical license – New Mexico, Board certification, 10+ years..., Managed care..., Experience with..., Strong physician leadership..., etc. We'll list each as
- . Preferred: list as
- items.
Skills: maybe we can extract from Required: Strong physician leadership, executive communication, business acumen, and influence skills. Also maybe from Preferred: advanced degree etc. We'll put skills in a
- .
Benefits: list as
- Senior Clinical Leadership: Serve as the senior physician executive for the health plan. Lead all Medical Directors and UM staff members including clinicians, and other clinical staff reviewers. Provide clinical leadership across affordability, quality, utilization, access, member outcomes, population health, and provider engagement. Advise executive leadership on clinical risk, utilization trends, medical cost drivers, medical policy, provider behavior, and quality improvement opportunities. Represent the health plan in physician, provider, regulatory, and delivery system forums.
- Utilization Management Decision Responsibility: Serve as the accountable clinical leader for UM medical necessity decision-making. Oversee adverse determinations, peer-to-peer review, appeals, reconsiderations, clinical escalation pathways, and physician reviewer consistency. Ensure UM decisions are evidence-based, timely, fair, well-documented, and aligned with applicable federal, state, accreditation, and plan requirements. Maintain clinical oversight of criteria, medical necessity rationale, denial language, decision consistency, and reviewer performance. Partner with the Healthcare Value Leader to ensure UM operations support timely and compliant clinical decisions. NCQA’s UM framework emphasizes objective, evidence-based criteria, relevant clinical information, qualified professionals, fair and timely decisions, and appropriate appeals handling.
- Medical Policy and Clinical Criteria: Own clinical governance for medical policies, clinical criteria, practice guidelines, and evidence-based care standards. Ensure policies are current, clinically appropriate, compliant, and operationally implementable. Partner with Compliance, Legal, Quality, Pharmacy, UM Operations, Network, and the Healthcare Value Leader on policy updates and implementation. Provide clinical leadership for coverage policy interpretation, new technology review, and emerging clinical practice changes.
- Clinical Oversight of Care Management: Provide clinical guidance for complex case management, disease management, transitions of care, high-risk member programs, and population health initiatives. Support the clinical design of care management programs while the Healthcare Value Leader owns operational execution. Participate in complex case escalation, avoidable utilization review, post-acute strategy, and clinical intervention design. Collaborate with CM Operations to ensure programs are clinically sound and focused on the right populations.
- Medical Cost and Utilization Leadership: Partner with the Healthcare Value Leader, Finance, Actuarial, Analytics, and Network to review medical cost and utilization trends. Provide physician leadership on initiatives related to inpatient utilization, ED utilization, post-acute care, specialty variation, site-of-care optimization, pharmacy trends, and avoidable admissions. Support development of clinical interventions that reduce unnecessary utilization while preserving access and quality. External CMO benchmarking includes accountability for leading medical cost and utilization analysis and correcting identified or anticipated utilization issues while assuring members receive needed care.
- Provider and Physician Engagement: Serve as the health plan’s senior clinical representative to physicians, provider groups, and delivery system leaders. Lead physician-to-physician
- .
Schedule (Work Arrangement): we have Remote: Open to applicants in the United States, excluding CA, IL, ND, NY, OH, WA, and WY. Hybrid: For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday. We'll put as
or
- . Probably
. We also have About Us and About New Mexico; we could incorporate into About the role as additional paragraphs after summary, or maybe a separate section "About the organization". Not in allowed headings but we could still include as
under About the role. The instruction: Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). It doesn't forbid other headings, but says use those for section headings. Safer to stick to those headings and put extra info under About the role. Thus About the role will contain location address, summary, and maybe About Us and About New Mexico paragraphs. We must not repeat job title as heading; fine. We must not include boilerplate like AA/EOE etc. Remove that line. Now produce HTML fragment. Let's craft. We'll need to escape any HTML special characters? Not needed. We'll produce:
About the role
Location Address: 9521 San Mateo NE Albuquerque, NM 87113-2237
The Chief Medical Officer is the senior physician executive responsible for the health plan’s clinical leadership, medical policy, clinical strategy, utilization management decision authority, medical necessity oversight, appeals, peer-to-peer review, and provider clinical engagement. In the refreshed model, the CMO should hold explicit accountability for UM decision responsibility, including medical necessity determinations, adverse determinations, clinical escalation, appeals, peer-to-peer review, and governance of medical criteria. The CMO should not be positioned as the primary operator of all UM and CM workflows. Those should sit with the Healthcare Value Leader. This is consistent with external health plan CMO benchmarking, where the CMO provides leadership for care management and utilization management programs, oversees appropriateness and medical necessity, develops clinical practice guidelines, leads medical cost/utilization analysis, and directs medical management decisions.
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees. Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans. We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great. Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC. New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
Then Responsibilities:Responsibilities