Staff VP, CMO Medicaid (hybrid)

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

This position requires work and residency within the state of Arizona.

Purpose of the job

The CMO/Medical Director shall actively provide oversight and management of the Quality Management, Quality Improvement, Maternal and Child Health, and Medical Management Programs within the Medicaid Segment; this includes direct oversight of the Adult and Childrens Healthcare Administrators and both physical and behavioral health services. This position has overall accountability and oversight of all Medicaid Segment AHCCCS Health Plan clinical functions and medical cost trends consistent with the vision and strategy set forth by the senior executive leadership team to ensure medical policies, procedures, and activities/actions of the segment are consistent with standards of good medical practice in the community. Actively involved in the shift towards a value-based, integrated delivery system in collaboration with strategic partners to ensure the delivery of the highest value healthcare services. This position is a key position within the AHCCCS contract and requires the incumbent to reside in the state of Arizona.

REQUIRED QUALIFICATIONS

Required Work Experience

• Minimum 5 years of clinical practice experience required
• Minimum 5 years of managed care experience required
• Minimum 5 years of experience with quality review, utilization review, and managed care functions
• Minimum 3 years of experience in developing short-and long-term range strategic plans, forecasting and budgeting
• Minimum 2 years NCQA experience

Required Education

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree

Required Licenses

• Active, current, and unrestricted license to practice medicine in the State of Arizona

Required Certifications

• Board certified in their medical specialty required

PREFERRED QUALIFICATIONS

• Preferred Work Experience
• 10 years of management experience
• 10 years of clinical experience in a primary care field
• 10 years of experience with quality review, utilization review, and managed care functions
• 5 years of experience in developing short-and long-term range strategic plans, forecasting and budgeting

Preferred Education

• MBA or MPH

Preferred Licenses

• N/A

Preferred Certifications

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

• Provide direction, support and medical expertise and oversight to areas within the clinical services, including utilization management, quality management, case management, medical claims review, and pharmacy management. Specific activities include outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, precertification, medical claims reconsideration and retrospective review.
• Designs and implements the appropriate infrastructure and staffing resources under the Adult and Childrens Healthcare Administrators in order to ensure that expertise for both physical and behavioral health services are available and integrated within the organization
• Ensures compliance with all accreditation and regulatory regulations.
• Provide input and guidance for company quality management programs and policies including HEDIS, CAPHS, and quality complaints and reviews.
• Provide senior clinical oversight, guidance, and administration of the Care Management Program, Disease Management Program, Provider Network Management administration and Credentialing Program in accordance with NCQA and URAC Standards.
• Serves as the Medicaid clinical expert.
• Establishes credibility and rapport to collaborate with a broad set of senior executives, clinicians, local government leaders, and community representatives.
• Participates and supports the communication, education, and maintenance of partnerships with contracted providers, provider physician groups, and may serve as the interface between the Health Plan and providers, regulators, etc.
• Manages, mentors, and coaches a high performing leaders and team members that are focused on clinical quality, service excellence, and business literacy; accountable for the success of Medical Directors contributing to the AHCCCS Health Plan.
• Rallies support for the overall corporate vision and able to provide competitive clinical strategies and plans to ensure delivery of the highest value clinical and service outcomes of all communities to which the position is assigned.
• Responsible for the financial health of the Plan related to medical cost trends.
• Collaborates with clinical leadership and key stakeholders to oversee the development and implementation of an effective care management infrastructure, including clinical practice improvement to reduce variation and improve efficiencies.
• Actively supports Quality and Compliance to ensure the Health Plan meets and exceeds medical management, quality, accreditation, regulatory, and agency standards.
• Accountable for ongoing monitoring, measurement, and communication of medical management programs and processes (e.g. utilization management, care management, etc.); overseeing analysis of overall medical expense and performance data.
• Facilitates timely and specific clinical behavior modification that is both clinically sound and cost effective.
• Use population health and value-based care management in developing and evaluating systems that fully integrate care and reimbursement across the continuum of health care delivery.
• Accountable for adoption of evidence based medical guidelines and protocols with proper stewardship of resources, analyzing members and population data to guide program direction.
• Participates in the administration of medical management programs to assure that network providers deliver, and members receive appropriate, high quality, and cost-effective care.
• Responsible for recommending changes and enhancements after investigation of cases deviating from evidence-based and/or accepted practice standards and takes appropriate actions.
• Leads the charge in focus and implementation of the organization's culture and strategic plan in a way that aligns to the mission, vision, and values of the organization.
• Oversee day-to-day departmental administration by coaching and motivating managerial staff and departmental personnel to make maximum use of experience and skills.
• Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.
• Coordinate activities between multiple divisions to achieve desired results.
• Perform all other duties as assigned
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements

REQUIRED COMPETENCIES

Required Job Skills

• Proficiency with managed care environment with a philosophy of collaboration and team work
• Ability to process map and manage large projects to successful completion

Required Professional Competencies

• Strong analytic skills with the ability to draw conclusions and translate complicated data into useable information that can be clearly communicated.
• High tolerance for complex, ambiguous, and shifting environments, including a matrix management structure
• Ability to generate creative solutions, identify the best course of action and rapidly resolve complex issues/problems
• Skill in resolving employee/customer conflicts and complaints in a mutually satisfactory way
• Ability to communicate clearly with employees at all organizational levels, and across differing cultural backgrounds, with ability to build consensus

Required Leadership Experience and Competencies

• Demonstrated organizational and project management skills to manage complex projects through effective planning, tracking, and resource allocation to meet business objectives and timelines.

• Strong leadership and management skills. Knowledge of methods used for improving employee performance/motivation

PREFERRED COMPETENCIES

Preferred Job Skills

• N/A

Preferred Professional Competencies

• N/A

Preferred Leadership Experience and Competencies

• N/A

Our Commitment

AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.