Chief Medical Officer

Job Summary

The Chief Medical Officer oversees all clinical management and services of the organization, ensuring compliance with the ACO REACH Program and other services. The Chief Medical Officer provides leadership to the medical staff and the health services functions, ensuring alignment of services provided to the needs to the program. The Chief Medical Officer acts as an advocate for ilumed and the ACO REACH program, and plays a critical role in strategic planning and program messaging. The Chief Medical Officer provides strong leadership, critical medical expertise, and is responsible for driving quality outcomes and compliance within the healthcare environment.

Essential Job Function

• Plans, organizes, and directs the professional medical services program, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs.
• Regularly reviews clinical performance of Participant Providers and Preferred Providers as defined in the ACO REACH program as well as ancillary providers such as hospitals, health systems, specialists, etc.
• Reviews and reports on patient data analytics including (a) medical record and billing reviews, (b) training for Participant Providers and their staff as well as Employer's administrative team regarding medical and billing record preparation and reporting,
• Undertakes quality assurance or utilization reviews whether prospective, retrospective, or concurrent, and (d) advise and supervise regarding inpatient and outpatient coding including Healthcare Effectiveness and Data and Information Set ("HEDIS") measurement and reporting, Medical Loss Ratio("MLR") measurement and reporting, Hierarchical Condition Category Coding ("HCCC") measurement and reporting, Diagnosis Related Group (''DRG") and Current Procedural Terminology ("CPT") measurement and reporting, (g) International Classification of Diseases, Clinical Modification ICD-10-CM/PCS ("ICD l0") measurement and reporting-each as may be amended or supplemented from time to time or as otherwise required by the ACO REACH Program.
• Actively participates in staff and management meetings, Parent and Ilumed board meetings and prepares reports as directed by the CEO.
• Develops and presents educational programs on behalf of Employer regarding Minimum Clinical Measures.
• Participates in the structure and implementation of compliance audits and corresponding presentation to the Boards of Directors and members of the ilumed System.
• Advocates on behalf of Employer as a participant in the ACO REACH Program; and
• Regularly reviews adequacy of documentation to support diagnoses (validation) consistent with the Minimum Clinical Measures
• Identifies opportunities to improve identification and management of conditions for ACO REACH beneficiaries
• Identifies and reviews with Participant Providers patient conditions lacking adequate management: Undertakes corrective action and regularly report on clinical management activities as directed by CEO.
• Participates in risk management, claim adjudication (when applicable), pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing and profiling.
• Regularly reviews Participant Provider operations and reporting which review anticipates in-person travel by Chief Medical Officer
• Prepares and updates disease screening-identifying potential conditions ilumed should screen for and identify using different modalities and assist in the development of a chronic disease treatment program.
• Reviews and monitors referral requests by Participate Providers and self-referrals by ACO REACH beneficiaries. When appropriate, actively participate in related education and training about alternative approaches to avoid requirements for referral or to improve results from referrals.
• Maintains up-to-date knowledge of new information and technologies in medicine and their application.
• Performs and oversees in-service staff training and education of professional staff.
• At the direction of the CEO or with the consent of the CEO, represents Company at medical group meetings, conferences, etc.
• Participates in the development of strategic planning for existing and expanding business.
• Recommends changes in program content in concurrence with changing markets and technologies.
• Provides professional leadership and direction to the Employer's operations with particular emphasis on Employer's Medical Management and Reporting activities (Utilization/Cost Management/Clinical Quality Management and related reporting to CMS).
• Collaborates with other senior managers in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes
• Assists in creating a compliant and high-performance network that meets the needs and requirements of the ACO REACH Program.
• Maintains up-to-date knowledge of new information and technologies in medicine and their application.
• Performs other duties as assigned.
  
  

Knowledge, Skills And Competencies

• Strong background in healthcare leadership, policy development and execution as well as relationship management.
• Strong understanding of utilization management as well as standard utilization and financial metrics.
• Strong ability to analyze utilization and communicate with providers regarding gaps in care and provide suggestions and solutions.
• Familiarity with accountable care organizations, concepts and goals.
• Strong understanding of population health management and the ability to apply concepts to physician practice improvement.
• Strong ability to communicate provider performance based on ilumed measurements and identify opportunities to consider change.
• Able to relate cooperatively and constructively with patients, families, and co-workers.
• Ability to communicate verbally and in writing.
• Maintains confidentiality of sensitive information.
• Ability to problem solve to formulate a plan of care and evaluate the patient's response to care.
• Ability to interpret, adapt, and react calmly under stressful conditions.
• Ability to manage multiple projects and conflicting priorities.
• Microsoft Office including Word, Excel and PowerPoint
  
  

Education And Experience

• Doctor of Medicine or Doctor of Osteopathy from an accredited medical school
• Current state medical license and in good standing with medical board
• 15 years in primary care, family medicine, or comparable specialty
• 7 – 10 years of Medical Director or similar leadership experience in primary care.
• Experience with data analytics programs and reporting.
• Experience in practice transformation as it pertains to the “Triple Aim”; reduction of the per capita cost of care through quality care and improved patient experience.
  
  

Physical Requirements

• Prolonged periods of sitting at a desk and working on a computer.
• Travel 25% or more
  
  

Additional Information

• Must abide by all HIPAA, Confidentiality & Privacy Laws
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.
  
  

Disclaimer

Job descriptions are not meant to be all-inclusive and/or the job itself is subject to change. Nothing in this job description restricts ilumed’s right to assign or reassign duties and responsibilities to this job at any time.