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Chief Medical Officer
Location : California, San Diego
Refer job # YKVO340231

Job Responsibilities and Requirements: These responsibilities include development and implementation of medical programs/policies, enhancing relationships with providers and facilities, plan sponsors and regulatory agencies. The CMO acts as a key business partner in network development, product design, strategic planning, regulatory compliance and community outreach. The ideal candidate will have previous Medicaid/Medi-Cal Managed Care experience having worked with state regulators and executed on strategic initiatives and programs. Strong leadership experience, strategic vision and a proven ability to execute on clinical initiatives are a must have in this position. Candidates who have Medicare experience would be considered though Medicaid/Medi-Cal is highly preferred. Previous experience with Medicaid/Medi-Cal Long Term Care / MLTSS/ TANF / SPD /MCE and CHIP populations, and, pharmacy benefit management and behavioral health integration experience highly preferred. A thorough understanding and experience working in a delegated and non-delegated delivery model is highly preferred. Excellent Communication skills are a must. The CMO will act as the Clinical Leader for Aetna Better Health of California and must be willing to travel throughout the state on an as needed basis. Relocation Assistance provided if necessary. The CMO will be located in the San Diego, CA office. Fundamental Components: Provides clinical and business leadership in support of strategic business objectives. Responsible for leadership of medical management activities that meet the strategic needs of business segments and plan sponsors. Participates in evaluation of product design; impact on quality, care and service. Participates in short and long range program planning, total quality management and external relationships. Responsible for the design and implementation of medical policies, goals and objectives. Provides professional leadership and direction to the functions within the medical management department. Responsible for the development of budgets, staffing plans, assuring the adequate allocation of resources. Monitors member and provider satisfaction survey results and implement changes. Actively and credibly discusses complex care situations with clinicians and clarifies Aetna s plan, contract and policy parameters in complex and non-standard medical situations. Participates in the development of strategic planning for existing and expanding business. Uses data analysis to identify opportunities for quality improvement and to positively influence practice patterns, plan sponsor trends or benefit plan designs. Conducts up-front analysis of policy, systems, and regulatory changes to manage impact and interdependencies. Develops and improves tools to support Aetna's medical management programs. Expands Aetna's medical management programs to address member needs across the continuum of care. Ensures rigorous, consistent and disciplined design and execution of medical management programs. Partners with other medical management functional organizations to ensure consistency and standardization of policy and procedures. Develops, manages and builds teamwork among a diverse group of medical management professionals. Promotes quality and medical appropriateness of care. Has responsibility for development and implementation of multiple medical management initiatives and achievement of desired performance. Leads quality management activities at regional and market levels including those necessary to achieve NCQA and URAC accreditation. Has responsibility for overall Utilization Management, Case and Disease Management for delegated and non-delegated members, establishing appropriate oversight of these functions. Has responsibility for resolving member grievances and appeals related to clinical matters. Works collaboratively with other functional areas that interface with medical management including provider relations, member services, sales, benefits and claims management, health care delivery, national medical services and national accounts. Oversees triage and referral for behavioral health staff in respective regions/units (Behavioral Health Medical Director). Acts as critical medical leader for external providers and plan sponsors, including regulatory & accrediting agencies, and community organizations that support Medicaid members. Has responsibility to provide 24/7 access. Background / Experience: 3 - 5 years of experience in the health care delivery system, e.g. clinical and health care industry required with 3 - 5 years of additional leadership and management experience managed care. Demonstrated ability to create business strategy to drive competitive advantage and shift direction as market conditions dictate. Demonstrated ability to interact successfully with external providers. Demonstrated ability to work in delegated and non-delegated models with focus on members getting timely and appropriate medical care. Education: The highest level of education desired for candidates in this position is a MD or DO. Licenses and Certifications M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience. Active and current state medical license without encumbrances in the State of California or ability to obtain medical license in California is a requirement for this position.



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