Chief Medical Officer - Health Plan (Hybrid or Remote)
for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Use - for any list of duties/requirements/benefits, and
for prose. Do NOT repeat job title as heading. Do NOT put Job ID/requisition numbers as headings. Preserve all substantive info. Remove boilerplate: cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, application instructions. Include a section ONLY when posting has real, specific content for it — never emit heading followed by filler/placeholder text. Prefer few substantive sections over many thin ones.
We need to parse the posting.
Key info:
Location Address: 9521 San Mateo NE Albuquerque, NM 87113-2237
Summary: description of role.
Work Arrangement: 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.
Job Description sections: 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: (Education, Certifications and Minimum Job Requirements) Required MD or DO from an accredited medical school Active, unrestricted medical license – New Mexico Board certification 10 or more years of relevant clinical and health care leadership experience Managed care, health plan, medical director, UM, quality, population health, or medical management leadership experience Experience with medical necessity review, appeals, peer review, clinical criteria, medical policy, and regulatory/accreditation requirements Strong physician leadership, executive communication, business acumen, and influence skills Preferred Prior experience as a health plan CMO, deputy CMO, associate CMO, or senior medical director Experience in Medicare Advantage, Medicaid, commercial health plan, provider-sponsored health plan, or integrated delivery system Experience with NCQA, URAC, CMS, state regulatory requirements, HEDIS/Stars, value-based care, behavioral health integration, and risk adjustment Advanced degree such as MBA, MHA, MPH, MMM, or equivalent CPHQ, CPE, or equivalent physician leadership/quality credential
Benefits: Benefits are effective day-one (for .45 FTE and above) and include: Competitive salariesFull medical, dental and vision insuranceFlexible spending accounts (FSAs)Free wellness programsPaid time off (PTO)Retirement plans, including matching employer contributions Continuing education and career development opportunitiesLife insurance and short/long term disability programs
About Us: description of Presbyterian Healthcare Services.
About New Mexico: description.
We need to decide sections: Could have About the role (summary), Responsibilities (list of duties), Requirements (education, certifications, experience), Qualifications (maybe preferred), Skills (maybe leadership skills), Benefits (list), maybe Work Arrangement (location/hybrid) could be part of About the role or separate? The instruction says use headings for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. So we can include those that have content.
We have no explicit Pay or Schedule info besides hybrid schedule (Tuesday-Thursday in-office). That could be Schedule. The posting mentions hybrid schedule: in-office presence required Tuesday through Thursday. That's schedule info. So we can include a Schedule section with that detail.
We have location address and remote eligibility; could be part of About the role or maybe separate but we can incorporate into About the role.
We need to avoid filler like "commensurate with experience". Not present.
We need to remove boilerplate: AA/EOE/VET/DISABLED etc. Also "PHS is a drug-free..." etc. Remove.
We need to preserve all substantive info.
Let's structure:
About the role
Location: 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. ... (summary). Work arrangement: 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 required Tuesday through Thursday.
But we also have separate Schedule section maybe.
Better: About the role includes summary and location. Schedule section includes hybrid days.
Responsibilities: list of duties from Senior Clinical Leadership etc. Could be a .
Requirements: education, certifications, minimum job requirements (MD/DO, license, board certification, 10+ years experience, etc.)
Qualifications: preferred experience (prior CMO, Medicare Advantage, etc.) maybe also advanced degree.
Skills: strong physician leadership, executive communication, business acumen, influence skills.
Benefits: list.
We need to avoid duplication.
Let's extract details.
From 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. 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 can incorporate that into About the role.
Responsibilities: list from sections:
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.
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.
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 conversations on medical necessity, utilization variation, care standards, documentation, quality improvement, and value-based performance.
- Support provider education related to clinical criteria, medical policies, UM expectations, appeals, and evidence-based practice.
Quality, Risk Adjustment, and Behavioral Health Partnership:
- Partner with the SVP Quality, Behavioral Health, and Risk Adjustment to ensure clinical strategy aligns with quality, risk adjustment, behavioral health integration, equity, accreditation, and regulatory requirements.
- Provide clinical support for HEDIS, Stars or equivalent quality programs, care gap closure, chronic disease management, and clinical quality initiatives.
- Avoid duplicating the SVP Quality/BH/RA role by focusing on clinical authority, medical necessity, medical policy, and physician engagement.
Additional Job Description Other Information: (Education, Certifications and Minimum Job Requirements) - list.
We'll create Requirements section with those.
Qualifications: Preferred experience list.
Skills: Strong physician leadership, executive communication, business acumen, and influence skills.
Benefits list.
Schedule: Hybrid schedule: in-office presence required Tuesday through Thursday for those within 60 miles of Albuquerque. Remote open to US excluding certain states.
We could also include location in About the role.
Now ensure we don't include filler like "Competitive salariesFull medical..." need to separate with spaces. The benefits text: "Competitive salariesFull medical, dental and vision insuranceFlexible spending accounts (FSAs)Free wellness programsPaid time off (PTO)Retirement plans, including matching employer contributions Continuing education and career development opportunitiesLife insurance and short/long term disability programs". It seems missing spaces; we should preserve as is but maybe add spaces for readability? The instruction: preserve ALL substantive information; do NOT invent or summarize away detail. So we should keep the exact text but we can format as list items. The text currently lacks spaces between items; we could split by capital letters? But better to keep as is but we can still make list items each benefit separated by maybe we need to insert spaces? The original text: "Competitive salariesFull medical, dental and vision insuranceFlexible spending accounts (FSAs)Free wellness programsPaid time off (PTO)Retirement plans, including matching employer contributions Continuing education and career development opportunitiesLife insurance and short/long term disability programs". It seems they omitted spaces after each benefit. We could preserve that string as a single paragraph? But they said use - for any list of benefits. So we need to split into items. We need to infer where each benefit ends. Likely each benefit starts with a capital letter after the previous benefit ends without space. Let's parse:
"Competitive salaries" then "Full medical, dental and vision insurance" then "Flexible spending accounts (FSAs)" then "Free wellness programs" then "Paid time off (PTO)" then "Retirement plans, including matching employer contributions" then "Continuing education and career development opportunities" then "Life insurance and short/long term disability programs".
Thus we can split accordingly.
We'll produce
- Competitive salaries
etc.
Now About Us and About New Mexico: Are they substantive? Could be included as About the company maybe but not in prescribed headings. The instruction says use headings for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. It doesn't forbid other headings, but says "Prefer a few substantive sections over many thin ones." Could we include About Us as a section? Not in list but could be considered "About the role"? Probably not. The instruction: "Use for section headings (e
for prose. Do NOT repeat job title as heading. Do NOT put Job ID/requisition numbers as headings. Preserve all substantive info. Remove boilerplate: cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, application instructions. Include a section ONLY when posting has real, specific content for it — never emit heading followed by filler/placeholder text. Prefer few substantive sections over many thin ones. We need to parse the posting. Key info: Location Address: 9521 San Mateo NE Albuquerque, NM 87113-2237 Summary: description of role. Work Arrangement: 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. Job Description sections: 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: (Education, Certifications and Minimum Job Requirements) Required MD or DO from an accredited medical school Active, unrestricted medical license – New Mexico Board certification 10 or more years of relevant clinical and health care leadership experience Managed care, health plan, medical director, UM, quality, population health, or medical management leadership experience Experience with medical necessity review, appeals, peer review, clinical criteria, medical policy, and regulatory/accreditation requirements Strong physician leadership, executive communication, business acumen, and influence skills Preferred Prior experience as a health plan CMO, deputy CMO, associate CMO, or senior medical director Experience in Medicare Advantage, Medicaid, commercial health plan, provider-sponsored health plan, or integrated delivery system Experience with NCQA, URAC, CMS, state regulatory requirements, HEDIS/Stars, value-based care, behavioral health integration, and risk adjustment Advanced degree such as MBA, MHA, MPH, MMM, or equivalent CPHQ, CPE, or equivalent physician leadership/quality credential Benefits: Benefits are effective day-one (for .45 FTE and above) and include: Competitive salariesFull medical, dental and vision insuranceFlexible spending accounts (FSAs)Free wellness programsPaid time off (PTO)Retirement plans, including matching employer contributions Continuing education and career development opportunitiesLife insurance and short/long term disability programs About Us: description of Presbyterian Healthcare Services. About New Mexico: description. We need to decide sections: Could have About the role (summary), Responsibilities (list of duties), Requirements (education, certifications, experience), Qualifications (maybe preferred), Skills (maybe leadership skills), Benefits (list), maybe Work Arrangement (location/hybrid) could be part of About the role or separate? The instruction says use headings for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. So we can include those that have content. We have no explicit Pay or Schedule info besides hybrid schedule (Tuesday-Thursday in-office). That could be Schedule. The posting mentions hybrid schedule: in-office presence required Tuesday through Thursday. That's schedule info. So we can include a Schedule section with that detail. We have location address and remote eligibility; could be part of About the role or maybe separate but we can incorporate into About the role. We need to avoid filler like "commensurate with experience". Not present. We need to remove boilerplate: AA/EOE/VET/DISABLED etc. Also "PHS is a drug-free..." etc. Remove. We need to preserve all substantive info. Let's structure:
About the role
Location: 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. ... (summary). Work arrangement: 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 required Tuesday through Thursday.
But we also have separate Schedule section maybe. Better: About the role includes summary and location. Schedule section includes hybrid days. Responsibilities: list of duties from Senior Clinical Leadership etc. Could be a- .
Requirements: education, certifications, minimum job requirements (MD/DO, license, board certification, 10+ years experience, etc.)
Qualifications: preferred experience (prior CMO, Medicare Advantage, etc.) maybe also advanced degree.
Skills: strong physician leadership, executive communication, business acumen, influence skills.
Benefits: list.
We need to avoid duplication.
Let's extract details.
From 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. 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 can incorporate that into About the role.
Responsibilities: list from sections:
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.
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.
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 conversations on medical necessity, utilization variation, care standards, documentation, quality improvement, and value-based performance.
- Support provider education related to clinical criteria, medical policies, UM expectations, appeals, and evidence-based practice.
Quality, Risk Adjustment, and Behavioral Health Partnership:
- Partner with the SVP Quality, Behavioral Health, and Risk Adjustment to ensure clinical strategy aligns with quality, risk adjustment, behavioral health integration, equity, accreditation, and regulatory requirements.
- Provide clinical support for HEDIS, Stars or equivalent quality programs, care gap closure, chronic disease management, and clinical quality initiatives.
- Avoid duplicating the SVP Quality/BH/RA role by focusing on clinical authority, medical necessity, medical policy, and physician engagement.
Additional Job Description Other Information: (Education, Certifications and Minimum Job Requirements) - list.
We'll create Requirements section with those.
Qualifications: Preferred experience list.
Skills: Strong physician leadership, executive communication, business acumen, and influence skills.
Benefits list.
Schedule: Hybrid schedule: in-office presence required Tuesday through Thursday for those within 60 miles of Albuquerque. Remote open to US excluding certain states.
We could also include location in About the role.
Now ensure we don't include filler like "Competitive salariesFull medical..." need to separate with spaces. The benefits text: "Competitive salariesFull medical, dental and vision insuranceFlexible spending accounts (FSAs)Free wellness programsPaid time off (PTO)Retirement plans, including matching employer contributions Continuing education and career development opportunitiesLife insurance and short/long term disability programs". It seems missing spaces; we should preserve as is but maybe add spaces for readability? The instruction: preserve ALL substantive information; do NOT invent or summarize away detail. So we should keep the exact text but we can format as list items. The text currently lacks spaces between items; we could split by capital letters? But better to keep as is but we can still make list items each benefit separated by maybe we need to insert spaces? The original text: "Competitive salariesFull medical, dental and vision insuranceFlexible spending accounts (FSAs)Free wellness programsPaid time off (PTO)Retirement plans, including matching employer contributions Continuing education and career development opportunitiesLife insurance and short/long term disability programs". It seems they omitted spaces after each benefit. We could preserve that string as a single paragraph? But they said use
- for any list of benefits. So we need to split into items. We need to infer where each benefit ends. Likely each benefit starts with a capital letter after the previous benefit ends without space. Let's parse:
"Competitive salaries" then "Full medical, dental and vision insurance" then "Flexible spending accounts (FSAs)" then "Free wellness programs" then "Paid time off (PTO)" then "Retirement plans, including matching employer contributions" then "Continuing education and career development opportunities" then "Life insurance and short/long term disability programs".
Thus we can split accordingly.
We'll produce
- Competitive salaries etc. Now About Us and About New Mexico: Are they substantive? Could be included as About the company maybe but not in prescribed headings. The instruction says use headings for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. It doesn't forbid other headings, but says "Prefer a few substantive sections over many thin ones." Could we include About Us as a section? Not in list but could be considered "About the role"? Probably not. The instruction: "Use
for section headings (e