Chief Medical Officer

Altais•Hybrid - CA, CA

4d•$294,525 - $385,560

About The Position

The Chief Medical Officer, Health Value plays a vital role in both the development and implementation of Care management and Utilization Management policy and procedures. This physician is chosen based upon knowledge of medical practice, experience in Managed Care, Utilization, Management/Quality Management programs and an ability to obtain mutual respect from and interact well with the other physicians. This role will lead and work to continually enhance the overall efficiency and quality of care for patients served by Altais Health Solutions through effective network management. As the leader of the team, this role develops and maintain collaborative functioning relationships with key providers, particularly thought leaders, across the Altais Health Solutions service delivery footprint including providing information for Altais Health Solutions to enable better understanding and skill enhancement in the medical, financial, and utilization practice functions of managed care.

Requirements

Doctor of Medicine degree
Current Board certification, in Internal Medicine, Family Practice, or Geriatrics.
Active and in good standing MD licensure in the state of California.
A minimum of ten (10) years as a practicing inpatient and outpatient physician in a managed care environment
6 years management experience
Health plan experience in operations
Experience in a physician group model

Responsibilities

Act as the primary medical leader responsible for interfacing with health plans regarding benefits, coverage issues, appeals, and administrative matters that cannot be resolved through standard channels.
Attend HMO hearings on appeals and provide clinical expertise in resolving escalated medical and administrative issues.
Serve as a key liaison between Altais Health Solutions, health plans, and provider organizations to ensure effective collaboration and resolution of disputes.
Provide clinical leadership and guidance to Primary Care Physicians (PCPs), specialists, and other providers across the AHS network.
Build and maintain strong relationships with key providers and thought leaders to enhance clinical integration and provider engagement.
Deliver ongoing education and training for PCPs and specialists to strengthen understanding of medical, financial, and utilization practices within managed care.
Chair the Credentialing Committee, ensuring all network providers meet the required qualifications, training, and expertise to deliver quality patient care.
Lead and provide oversight of the Utilization Management Committee (UMC), including chairing UM Committee meetings and presenting quarterly updates to the Clinical Advisory Group.
Oversee the development, implementation, and continuous refinement of UM and care management policies, procedures, and protocols to improve care coordination and ensure evidence-based clinical decision-making.
Guide and facilitate clinical rounds with Case Managers and Management to monitor utilization, ensure performance metrics (e.g., bed days) are met, and manage high-risk patient cases.
Serve as the lead physician liaison for UM and care management, providing clinical input into policies, system enhancements, and provider education efforts.
Lead and coordinate prospective, concurrent, and retrospective reviews, including denial and/or approval of outside medical service referrals, when necessary.
Oversee Quality and HEDIS programs, ensuring compliance with performance standards and driving initiatives to improve patient outcomes.
Lead efforts to enhance the patient experience across the AHS network through improved coordination, engagement, and satisfaction initiatives.
Participate as an active member of the Quality Management Committee, providing clinical expertise and recommendations for continuous improvement.
Accountable for Medical Loss Ratio (MLR) results across all lines of business and responsible for driving cost-effective care strategies without compromising health outcomes.
Lead claims and cost analyses to identify trends, variances, and opportunities for targeted interventions that improve clinical and financial performance.
Partner closely with physician leaders to ensure patient care is delivered efficiently and sustainably, balancing quality outcomes with cost containment goals.
Provide strategic leadership for the Pharmacy team, including oversight of clinical reviews, cost management, prior authorizations, and collaborative care models.
Work closely with payors, providers, and internal teams to optimize pharmacy utilization while maintaining high-quality patient care.
Reports to the Chief Physician Executive
Collaborate across departments to ensure seamless integration of clinical, financial, and operational strategies.
Act as a trusted advisor to leadership on medical management priorities, performance initiatives, and strategic planning.