Chief Medical Officer - Health Plan (Hybrid or Remote)

Presbyterian Healthcare Services

37d•Hybrid

About The Position

The Chief Medical Officer (CMO) is the senior physician executive responsible for the health plan’s clinical leadership, medical policy, clinical strategy, utilization management decision authority, medical necessity oversight, appeals, peer-to-peer review, and provider clinical engagement. In the refreshed model, the CMO should hold explicit accountability for UM decision responsibility, including medical necessity determinations, adverse determinations, clinical escalation, appeals, peer-to-peer review, and governance of medical criteria. The CMO should not be positioned as the primary operator of all UM and CM workflows. Those should sit with the Healthcare Value Leader. This is consistent with external health plan CMO benchmarking, where the CMO provides leadership for care management and utilization management programs, oversees appropriateness and medical necessity, develops clinical practice guidelines, leads medical cost/utilization analysis, and directs medical management decisions.

Requirements

MD or DO from an accredited medical school
Active, unrestricted medical license – New Mexico
Board certification
10 or more years of relevant clinical and health care leadership experience
Managed care, health plan, medical director, UM, quality, population health, or medical management leadership experience
Experience with medical necessity review, appeals, peer review, clinical criteria, medical policy, and regulatory/accreditation requirements
Strong physician leadership, executive communication, business acumen, and influence skills

Nice To Haves

Prior experience as a health plan CMO, deputy CMO, associate CMO, or senior medical director
Experience in Medicare Advantage, Medicaid, commercial health plan, provider-sponsored health plan, or integrated delivery system
Experience with NCQA, URAC, CMS, state regulatory requirements, HEDIS/Stars, value-based care, behavioral health integration, and risk adjustment
Advanced degree such as MBA, MHA, MPH, MMM, or equivalent
CPHQ, CPE, or equivalent physician leadership/quality credential

Responsibilities

Serve as the senior physician executive for the health plan.
Lead all Medical Directors and UM staff members including clinicians, and other clinical staff reviewers.
Provide clinical leadership across affordability, quality, utilization, access, member outcomes, population health, and provider engagement.
Advise executive leadership on clinical risk, utilization trends, medical cost drivers, medical policy, provider behavior, and quality improvement opportunities.
Represent the health plan in physician, provider, regulatory, and delivery system forums.
Serve as the accountable clinical leader for UM medical necessity decision-making.
Oversee adverse determinations, peer-to-peer review, appeals, reconsiderations, clinical escalation pathways, and physician reviewer consistency.
Ensure UM decisions are evidence-based, timely, fair, well-documented, and aligned with applicable federal, state, accreditation, and plan requirements.
Maintain clinical oversight of criteria, medical necessity rationale, denial language, decision consistency, and reviewer performance.
Partner with the Healthcare Value Leader to ensure UM operations support timely and compliant clinical decisions.
Own clinical governance for medical policies, clinical criteria, practice guidelines, and evidence-based care standards.
Ensure policies are current, clinically appropriate, compliant, and operationally implementable.
Partner with Compliance, Legal, Quality, Pharmacy, UM Operations, Network, and the Healthcare Value Leader on policy updates and implementation.
Provide clinical leadership for coverage policy interpretation, new technology review, and emerging clinical practice changes.
Provide clinical guidance for complex case management, disease management, transitions of care, high-risk member programs, and population health initiatives.
Support the clinical design of care management programs while the Healthcare Value Leader owns operational execution.
Participate in complex case escalation, avoidable utilization review, post-acute strategy, and clinical intervention design.
Collaborate with CM Operations to ensure programs are clinically sound and focused on the right populations.
Partner with the Healthcare Value Leader, Finance, Actuarial, Analytics, and Network to review medical cost and utilization trends.
Provide physician leadership on initiatives related to inpatient utilization, ED utilization, post-acute care, specialty variation, site-of-care optimization, pharmacy trends, and avoidable admissions.
Support development of clinical interventions that reduce unnecessary utilization while preserving access and quality.
Serve as the health plan’s senior clinical representative to physicians, provider groups, and delivery system leaders.
Lead physician-to-physician conversations on medical necessity, utilization variation, care standards, documentation, quality improvement, and value-based performance.
Support provider education related to clinical criteria, medical policies, UM expectations, appeals, and evidence-based practice.
Partner with the SVP Quality, Behavioral Health, and Risk Adjustment to ensure clinical strategy aligns with quality, risk adjustment, behavioral health integration, equity, accreditation, and regulatory requirements.
Provide clinical support for HEDIS, Stars or equivalent quality programs, care gap closure, chronic disease management, and clinical quality initiatives.
Avoid duplicating the SVP Quality/BH/RA role by focusing on clinical authority, medical necessity, medical policy, and physician engagement.