Chief Medical Officer Utilization Management

The Chief Medical Officer (CMO) Utilization Management will develop and manage efforts to improve and maintain cost and utilization trends.

Responsible for URAC, NCQA, state departments of insurance, and similar accreditors/regulators for the performance of all utilization management (UM) programs across the enterprise.

The CMO is individually responsible for overall clinical compliance within the UM programs, including matters concerning clinical policy, quality management (QM), program development, review of UM cases, clinical criteria, and provider issues, and always ensuring the clinical integrity and compliance of the programs.

Responsibilities and Essential Functions


* Responsible for development of clinical policy, clinical review decisions, appeals, audits, and other clinical functions, supported by program clinical leaders, and implement corrective actions when required


* Oversee the company's quality management program, including the development and implementation of internal quality monitors involving all operational areas of the organization and outcomes monitors focusing on potential over- and under-utilization of delegated services


* Oversee clinical policy development via the Medical Advisory Committee (MAC), and facilitate collaboration across clinical programs to ensure optimal process and content harmonization


* Collaborate closely with Compliance to ensure optimal performance at all audits conducted by NCQA, URAC, CMS, departments of insurance, or other outside regulators


* Evaluate utilization trends, referral patterns, fraudulent medical practices, quality standards, regulatory changes, program performance, and client feedback, and recommend solutions for improvement where needed, supported by program clinical leaders


* Set clinical strategy, planning, budgeting, and execution of annual goals for UM programs


* Provide thought leadership regarding trends in clinical management to direct new product strategy


* Provide executive clinical subject matter expertise (SME) for all UM strategic partnership opportunities related to UM services, which may include merger/acquisition activity


* Lead a dynamic culture of open communication, transparency, and flexibility across all stakeholders that fosters empowerment and personal development of individual employees


* Accountable for overall performance of all physician employees, including direct supervision of physician leaders in each UM program in close collaboration with business and operational leadership of the respective programs


* Collaborate with Operations leadership to ensure optimal clinical quality and operational efficiency of all UM programs


* Maintain strong relationship with clients' medical leadership concerning clinical policy, quality, program development, clinical criteria, and provider issues, supported by program clinical leaders


* Collaborate with the Analytics team to provide best-in-class analyt...