Chief Medical Officer - ConnectiCare

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Vice President
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2013L Requisition #
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Summary of Position

Provide the clinical leadership for ConnectiCare Medical Operations and Medical Quality both internally and externally; work with enterprise CMO to ensure implementation of strategies, policies, and processes.
Hire, develop, manage and motivate a performance-based team to maximize business results.
Improve the utilization of all medical services by contributing to the strategic direction for medical management programs including case management, prior authorization programs, grievance and appeals, disease management and pharmacy management. 
Work in conjunction with Data Analytics to assess medical trends and utilization and formulate appropriate medical management activities in advance of and response to trend; provide subject matter expertise and recommendations regarding policy/process improvements.

Principal Accountabilities

Responsible for establishing clinical policies and communicate the application of clinical policies internally and externally as they pertain to processes such as utilization management, quality management and pharmacy management. 
Medical policy lead for ConnectiCare which may include serving as chair or co-chair of enterprise wide medical policy committee.  CCI medical lead for executive complaints (member, provider, DOI, CMS)
May chair the ConnectiCare Physician Advisory Committee and the EmblemHealth Medical Policy Subcommittee.
Review/evaluate new technologies and their application in organizational clinical management programs.
Responsible for articulating Healthcare Management positions related to Operations claims configuration, claims payment and code management.  May act as a member of the Code Management Group. 
Work in conjunction with Product and Actuarial to provide input on proposed benefit changes and supports analysis of reports and data sets used to determine their success.
Lead physician supporting case management activities. Is an integral member of the case management teams and resolves case management questions and conflicts including interacting with attending physicians, physician advisors and IPA Medical Directors.
Interface with Emblem Health counterpart(s) by maintaining continued focus on developing and maintaining effective working relationships with EH counterparts to ensure ConnectiCare’s voice in heard on enterprise activities
Develop the skills and medical management capabilities of CCI internal physicians and external physician organizations and their medical directors.  
Cultivate cooperative relationships with their respective organizations. 
Lead physician participating in the management of pharmacy programs.  May act as a member of the Pharmacy and Therapeutic Committee.
Participates in the management of healthcare vendors including the articulation of medical policy and claims adjudication/configuration consistent with organizational policies and regulatory requirements.
May, in consultation with other leaders in Health Services, develop, refine and apply credentialing policy in accordance with NCQA standards.
Act as the lead Health Services resource concerning Medicare-risk policies and programs as they relate to medical and quality management of a Medicare population.
Consult with other leaders in Health Services to develop, refine and apply credentialing policy in accordance with NCQA standards.  Review all credentialing and re-credentialing applications for network providers and facilities; make recommendations to the PQIC for those requiring further review.
Represent Medical Affairs on the Medicare Steering Committee.
Participate in the development, implementation, ongoing analysis and improvement of new and established Commercial products and associated lines of business.
Support Sales/Marketing efforts to create new business opportunities, retain current business, and respond to customer and client needs.      
Perform other related projects and duties as assigned.
Education, Training, Licenses, Certifications

Licensed Physician (MD or DO).
Advanced degree desirable (MBA, MMM, MPH).
Board certified in area of expertise.
Primary care specialty or other Medicare population specialty desirable.
Unrestricted license to practice in CT and other states as appropriate/needed.

Relevant Work Experience, Knowledge, Skills, and Abilities

10+ years’ relevant professional experience. (R)
Primary care or other Medicare population specialty. (P)
At least 3 years clinical experience. (R)
Experience with Medicare-risk programs, preferably in a leadership role. (R)
Experience with the management of IPA, PHO and/or group practice models related to medical utilization, and/or resource management and quality assurance. (R)
Proven ability to communicate effectively (verbal, written, presentation, interpersonal) to all types/levels of audience. (R)
Public speaking experience; and the ability to persuade and influence. (R)
Ability to manipulate, analyze, and interpret data, especially healthcare related information. (R)
Computer literacy (word processing, database/spreadsheet, presentation, e-mail). (R)

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