What are the responsibilities and job description for the Vice President, Chief Medical Officer (Hybrid) position at CareFirst BlueCross BlueShield?

Resp & Qualifications

Note : We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities / deliverables that week.

PURPOSE :

Leads the organization's efforts to achieve excellence in healthcare affordability, quality, member experience, and improved population and member outcomes in both commercial and government program lines of business. Through deep operational and clinical expertise, drives the company-wide Quality Management program (including CMS Stars and risk adjustment), and the ongoing development and implementation of health care policy and technology assessment.
Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan members, targeting improvements in efficiency and satisfaction for members and providers. Serves as a clinical advisor / leader for teams dedicated to concurrent review, prior authorization, case management, disease management and clinical coverage review. Represents CareFirst in state and local level workgroups, task forces, and committees that address medical quality and cost.
Collaborates with other senior leaders on efforts that enhance the quality-of-care delivery, improve outcomes, and improve value delivered to our members and accounts.

ESSENTIAL FUNCTIONS :

Clinical Physician Executive Leader

The Vice President and Chief Medical Officer has the primary responsibility, as the lead physician executive for the Corporation, to provide strategic clinical direction for all programs promoting health equity, improved quality of care and managing cost of care. This role includes providing expert clinical consultation to executives throughout the organization.

Provides oversight and direction to for a team of physicians dedicated to CareFirst's mission to drive affordability, access, quality and equity in healthcare. Plays a highly influential and advisory role providing clinical and quality direction and oversight to care support programs.

Contributes to the development of strategic planning for existing and expanding business; recommends changes in program content in concurrence with changing markets and technologies.

Serves as medical subject matter expert, providing scientific / medical guidance to business initiatives / investments with the lens of the customer / patient experience.

May be asked to chair or be thought leader on various health plan committees and task forces both internal and external.

Medical Policy and Utilization Management Infrastructure

Oversees the Medical Policy team and adoption of national standard, evidence-based clinical guidelines to the extent possible. Develops, defines and recommends uniform medical policy with consistent application and care guidelines for the company.

Oversees and directs the rendering of medical management decisions at all levels of the health plan that maximize benefits for our members while pursuing and supporting corporate objectives and maintaining compliance with regulatory bodies.

Provides direction and oversight to all doctoral level professionals in the Health Services area, including those involved in medical necessity reviews, health care policy and technology assessment processes.

Provides support and a clinical escalation path to care management and utilization management staff, including RNs and non-professional staff.

Inpatient Management Oversight

Leads a team of clinical and non-clinical staff to manage the inpatient experience for CareFirst Members at hospitals in Maryland using a per diem methodology and at hospitals in the rest of the United States using a diagnostic related group (DRG) methodology.

SUPERVISORY RESPONSIBILITY :

This position manages people.

QUALIFICATIONS :

Education Level : Medical Degree in primary care specialty from an accredited medical school and an American residency in a primary care specialty. Must have current medical license in the State of Maryland (or credentials to apply for and be granted a Maryland license). Must have board certification.

Experience :

Minimum of 8 years clinical and administrative experience in a managed care setting.

Previous experience as medical director for a health care company.

At least 5 years as a leader of people and teams.

Preferred Qualifications :

In-depth knowledge of Medicaid and Medicare related programs in a health plan / payor environment, with solid understanding of Stars and risk adjustment.

Prior experience with operations management.

Previous experience collaborating with formal health economics function within corporate environment.

Ability to expand in scope and clinical leadership oversight as business needs evolve.

Knowledge, Skills and Abilities (KSAs)

Must possess excellent verbal and written communication skills. Knowledge and experience in utilization management and quality assurance.

Understanding of federal and state regulatory processes.

Knowledge and experience with national standard, evidence-based clinical guidelines.

Demonstrated leadership effectiveness in both formal and influencer roles; dynamic leader that motivates and inspires teams to achieve challenging targets.

Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers.

Salary Range : $348,800 - $523,200

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed.

Department

Health Services Leadership

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Where To Apply

Please visit our website to apply : www.carefirst.com / careers

Federal Disc / Physical Demand

Note : The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him / her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS :

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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Salary : $348,800 - $523,200

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Vice President, Chief Medical Officer (Hybrid)

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