About the Role
The Associate Chief Medical Officer is an executive level physician leader and a visible medical spokesperson for Horizon Blue Cross Blue Shield. This position has accountability for medical policy and/or medical review, appeals determinations, utilization management, clinical development of medical cost reduction initiatives, collaboration with care management program to optimize patient outcomes and participation and retention standards for all provider networks. The Associate CMO oversees a team of clinicians (physicians, nurses and others) and non-clinicians, and has responsibility and authority for medical and clinical quality decisions made within Horizon and its ventures. The Associate CMO develops and maintains strong relationships with members of the executive teams of key health systems and provider partners (including CEO, CMO and VP of Managed Care) and leverages these relationships to further the enterprise’s strategic goals or resolve emerging conflicts. The Associate CMO supports the development of clinical quality programs and achievement of the highest appropriate level of accreditation for Horizon.
What You'll Do
Set clinical strategy in line with the overall company vision and continually monitors Horizon BCBSNJ's utilization policies to ensure the company stays current with changing local and national trends; has accountability for all clinical decision making in line with the overall enterprise vision.
Accountable for the development of procedures and guidelines that will be used to monitor the specialized clinical services provided to members and establishes standards of care which identify desirable, observable characteristics of care based on current practice guidelines.
Responsible for working with medical management and cross functional teams to develop and implement clinical innovations to improve efficiencies and partnerships with providers.
Using metrics and data analytics, conducts root/ cause analysis to measure goal achievement and identify issues or trends that need remediation.
Responsible for development of clinical strategy. Implements Horizon BCBS medical cost reduction initiatives to achieve targeted savings and offset trends. Responsible for the identification of, contracting with and oversight of Delegated Vendors. Identify MCAP opportunities.
Ensures compliance with regulatory entities (DOBI, NCQA, DMAHS, and CMS) and may serves as clinical contact for regulators.
Serves as a spokesperson for the organization, focusing on quality healthcare delivery, providing leadership for clinical thinking for the company. Ensures review of medical records for medical necessity and appropriateness of care and ensures high quality, ethical clinical review procedures.
Builds a strong knowledge base of the providers in New Jersey while strengthening productive relationships and identifying areas for improvement; be recognized as a thought leader within the organization, the provider community, consumers and other key stakeholders in regards to clinical quality.
Partners with providers to successfully implement new programs aimed at increasing clinical quality and effectiveness. Maintains effective communication strategies with key external stakeholders and executive leadership of key external partners. Serves as liaison and represents Horizon BCBS NJ in contacts with internal and external stakeholder, and Governmental agencies.
Partners with the Vice Presidents for Network and with the VP and Chief Clinical Transformation Officer, to help shape clinical quality and performance for providers within the Horizon network and enforces clinical quality measures and guidelines. Helps shape clinical quality for new forms of partnerships with hospitals and providers.
Work closely with Network staff to develop high-quality physician networks; develops and implements a plan to remediate network practitioners who demonstrate aberrant practice patterns and quality of care.
Serves as a resource for Medical Directors in the review of cases referred by utilization management staff and as a resource for various other health services programs. Identifies and mitigate risks to the enterprise.
Regional Care Management, as applicable
Directs and manages operations and performance of programs in Regional Care Model. Provides clinical direction and leadership to promote continuous quality improvement within enterprise clinical operations. Accountable for medical management performance, for short term and long term strategic goals.
Provides adequate support for care management team to ensure that Care management performance guarantees are met. Ensures overall client satisfaction (including self-insured accounts) and appropriate level of service delivery.
Plays a lead role in integration of Behavioral and Physical Health.
Ensures/supports the adoption of the latest medical policies and clinical guidelines through the Horizon BCBSNJ organization and/or strives for consistency with national standardized practice and independent review organizations (IRO and IURO).
Works closely with Clinical Ops and Network staff to identify gaps in the provider network.
Supports value based team and value based partners in achieving enterprise goals. Works with Value Based Providers, develops and implements provider education programs related to clinical improvement activities and specialized programs.
Medical Policy, as applicable
Accountable for the implementation of and operational effectiveness of the Medical Policy/Code Integration/Medical Necessity Determinations across all lines of business.
Accountable for the development of medical policies for all lines of business. Evaluates national and local standards of care and review policies consistent with contracts for the books of business ensuring appropriate utilization of services.
Coordinates data analysis and provides leadership to the team in business process improvement initiatives expected to impact the efficiency and effectiveness of medical policy production and maintenance, code integration and maintenance and medical necessity determinations across all lines of business.
Oversees dental operations across lines of business.
Oversees clinical support to CBU team in securing new business and retaining existing ones.
Drives the latest medical policies through the Horizon BCBSNJ organization and/or strive for consistency with national standardized practice and independent review organizations (IRO and IURO).
What You Bring
Functional Competencies
Requires excellent understanding of the principles and concepts of managed care.
Requires knowledge of Government Programs including MLTSS, Medicare and Medicaid programs and principles.
Requires broad knowledge of utilization management and patient appeals process
Requires broad clinical knowledge and understanding of current health care issues and industry trends.
Requires a current active unrestricted license to practice medicine (MD or DO).
Board certification in an accepted medical specialty a plus or evidence of candidate remaining current with medical knowledge (e.g. up to date with NJ State CME requirements).
Requires a minimum of 10 years clinical experience.
Requires a minimum of 7 years of experience with medical management in a leadership role.
Requires experience working within a large, multi-level organization either within a health plan or provider organization.
Requires demonstrated success in implementing managed care policies, programs or initiatives.
Knowledge, Skills and Abilities:
Requires broad clinical skills to understand medical issues and to discuss them with attending physicians.
Requires the ability to interpret medical policy and provide guidance to others.
Requires the ability to exercise independent judgment in making medical necessity decisions.
Requires strong leadership skills.
Requires strong project management skills.
Requires excellent communication and presentation skills.
Requires analytical skills to evaluate data from various sources, identify trends/issues and to develop recommendations for senior management.
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Outlook; should be knowledgeable in the use of intranet and internet applications.
Requires strong listening skills and ability to find middle ground/opportunity for collaboration
Travel % (If Applicable):Travel within the States of NY, NJ and PA, as needed.
Salary Range:
$269,300 - $374,640
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
