Regional Chief Medical Officer, Health Plan Operations

Essence Group Holdings Corporation - St. Louis, MO

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Regional Chief Medical Officer, Health Plan Operations

Position Summary:
The Regional Chief Medical Officer is a member of the Lumeris Clinical Team and plays a key role in managing performance and performing medical management activities in our partnerships. The CMO is a member of the operations team and interacts with all aspects of the central operations including with the utilization management, case management and quality management teams within Lumeris to achieve the clinical, quality and financial goals. He/She works collaboratively across a matrix, entrepreneurial culture to provide clinical and population management expertise to Lumeris partners in the implementation and optimization of its provider engagement model, technologies, care delivery, and business processes. He/She will own the clinical and quality outcomes of the health plans while operating within a dyad model with the VP of Operations.

Reporting Relationship:
The Chief Medical Officer, Health Plan Operations reports directly to Chief Medical Officer, Health Plan Markets and is an active member of the Lumeris Clinical Team and the health plan operations team

Job Description:
Role and Responsibility

Provides clinical leadership in the development, organization and governance of a health plan at the market level
Responsible for leading the improvement of clinical, quality, and financial outcomes for the health plan and operating partnerships
Presents performance data at a market, line of business, physician group and physician level to the providers in market
Provides change management expertise in health systems, provider organizations, and physician practices
Collaborates with the Provider Engagement team to move physician offices to the accountable care model
Participates in the alignment of physician incentives, quality measures, and value-based contracts
Maintains strong relationships with Medical Directors and clinical leaders at partnering organizations
Directs and monitors medical management activities and quality management programs as needed to maintain compliance with CMS, NCQA and other accrediting bodies
Position Descriptions

As a Member of the Lumeris Clinical Team the CMO will:
Collaborate with the Corporate Chief Medical Officer (CCMO) and the Chief Medical Officer, Health Plan Markets on clinical strategy, design and approach, facilitating communications, and managing risk on active engagements as well as:

Act as an internal consultant on clinical program development and special projects for Lumeris customers.
Participate in ongoing product development activities related to Lumeris technologies and services.
Provide timely, proactive communications and progress reports to the Clinical Leadership Team and other key stakeholders regarding Lumeris activities and external client status.
Provide support to the Accountable Delivery Systems Institute as needed on matters relating to accountable care, physician engagement/alignment, payer and clinical transformation, and the use of leading technology in support of the new models of care.
Experience, Qualifications and Education

M.D. or D.O. degree, plus Board Certification. Current, unrestricted medical licensed (or eligible for licensure) in multiple states
Minimum of five years of successful clinical practice experience.
Minimum of three years of health plan or capitated provider experience with exposure to: utilization management, quality management, peer review, case management, denial/appeals, disease management, HEDIS reporting, and provider relations,
Prior leadership experience a plus.
Government sector experience a plus (Medicare or Medicaid products).
Excellent communication and problem-solving skills.
Demonstrated track record of building productive working relationships with peers, senior leadership, and external partners.
High level of energy and drive.
Flexible personality; easily adaptable to change/ambiguity.
Domestic travel required (up to 50%, location dependent).
Knowledge of healthcare financing and the relation to various managed care products (HMO, PPO, Indemnity, and especially Medicare Advantage).
Knowledge of continuous quality improvement theory and practice.
Candidate will primarily serve a regional client/clients and will make regular trips to the headquarters in St. Louis, MO and primary client sites.
Lumeris is an EEO/AA employer M/F/V/D.

St. Louis, MO

Time Type:
Full time