Chief Medical Officer
Job: Chief Medical Officer
Location: Chula Vista, CA
Job Description: Morgan Consulting Resources, Inc. has been retained to conduct the national search for the Chief Medical Officer for Community Health Group (CHG), a non-profit health plan based in San Diego County, California. This is a fantastic opportunity to join an outstanding leadership team within a mission-driven organization that is well known for its strong commitment to members.
About the organization:
The plan began as a small Medi-Cal health plan in 1982 and has grown from a base of 2,500 members to over 300,000 in their 30+ years in business, serving all of San Diego County. Today, CHG has enrollees in their Medi-Cal program and in a comprehensive new plan – CommuniCare Advantage Cal MediConnect Plan that combines Medicare and Medi-Cal benefits into one plan.
As a not for profit 501(c)(3) plan, CHG is committed to serving the underserved populations in their market. They have consistently been recognized for their outstanding customer service from staff, community, providers and members. The Health Plan is accredited by NCQA and has been recognized for its quality initiatives especially as it relates to HEDIS scores. CEO, Norma Diaz, says ‘We have been dedicated to coordinating quality health care in a manner culturally sensitive to all San Diego residents.’ For more information about the company, visit their website at www.chgsd.com.
About the position:
Reporting to the CEO, the CMO will be responsible for overseeing all clinical aspects of health services functions including Quality Improvement, Care Management, Utilization Management, Pharmacy and Behavioral Health. S/he will provide clinical leadership within the organization and ensure that quality targets and regulatory requirements are met. The CMO plays a key role in building relationships with the contracted physician network and will be spend much of their time in the community working directly with the contracted network addressing various issues. Additionally, s/he will ensure the appropriate clinical infrastructure is in place to support the Plan’s complex membership. The CMO will have a direct impact on the quality of care that is delivered to members and will help enhance the care management program.
We are looking for candidates with a strong quality improvement/care management background and solid leadership experience who excel in mission driven, culturally diverse organizations. The ideal candidate will approach this position with a high level of innovation, creativity and integrity. A sense of humility and excellent interpersonal skills are a must. The ability to build solid relationships with the community clinics and hospitals will be essential to the CMO’s success. Experience with government programs is required and exposure to Medi-Cal and Medicare is a huge plus. S/he must be comfortable in fluid environments and be able to respond quickly to changing regulations.
- Participates in the development of the organization’s budget, strategic and operational plans, and risk management activities.
- Establishes medical policy for guidance to the health services division.
- Oversees the development of utilization management and quality improvement programs, as well as medical necessity definition and criteria.
- Oversees the development and implementation of the health plan’s clinical guidelines and protocols that can be utilized through the quality improvement, utilization management, and case management processes to positively impact the delivery of care.
- Ensures division management and staff competency and compliance with applicable responsibilities and statues and regulations.
- Serves as Chairperson for the following committees: Quality Improvement, Utilization Management, Peer Review, and Credentialing.
- Recommends medical and ancillary service providers and hospitals for contract development.
- Presents and participates in educational programs, reviews current literature and trends, participates on committees and in meetings as assigned.
- Develops and maintains positive relationships with contracted physicians, community clinics, and hospital networks.
- Promotes a positive image of the organization and the department in all aspects of communication and contact.
- Establishes a framework for ongoing assessments of each functional area to identify opportunities for improvement, document the process and analyze possible solutions prior to implementation.
- Creates structures and systems to evaluate, update and change current processes that no longer contribute to the organization’s efficiency or efficacy.
- Establishes performance and productivity standards for each direct report within the division.
- Works closely with direct reports to ensure data is collected, collated, analyzed and distributed to providers as a means to provide and improve cost effective care and services.
- Provides leadership and mentoring as necessary to ensure all managers and staff are educated and trained in their respective roles, including ensuring that each manager and staff have an understanding of the impact of their role on downstream functions.
- Ensures that all areas are kept current in terms of strategies and practices used to make determinations, coordinate care and services, and process workflow.
- Ensures that communication within all aspects of health services is conducted in a timely and professional manner.
- Establishes a work environment conducive to open communication, allowing staff participation in identifying and resolving problems.
- Ensures all functional areas are compliant with HIPPA regulations, and that appropriate security measures are in place to prevent inappropriate disclosure.
- Ensures that providers have relevant and timely information.
- Ensures communication linkages with all departments to ensure smooth upstream and downstream processes, including the coordination of delay, modification, and denial determinations and notifications.
Confidentiality and Compliance:
- Participates in departmental and organization wide activities and programs to promote compliance with state and federal statutes (including CMS and/or Medicare Part D, DHCS and DMHC), and health plan and organizational policies and standards.
- Keeps individual information, as well as clinical information, confidential and ensures that requests for information are responded to in an appropriate fashion.
- Notifies the Chief Executive Officer immediately of any potential or real breach in confidentiality or compliance.
- Establishes division-wide policy related to fraud and abuse, and monitors compliance on an ongoing basis.
- Ensures that all staff members are educated relative to fraud and abuse, privacy, protected information and related security measures.
- Works with the Utilization Management Manager to ensure timely procedures and practices, and to implement a philosophy of “one and done” throughout the division.
- Works with contracting and provider relations to ensure early detection of, and possible prevention of, a decrease in provider performance.
- Reviews systems and processes that track specific and aggregate cases and utilization patterns that may adversely impact care, services or cost.
- Ensures development, along with the Chief Information Officer, databases specific to population targets to facilitate effective case management and chronic care coordination.
- Must be a graduate of an accredited school of medicine with a current unrestricted California license.
- MHA, MPH or MBA preferred.
- Working knowledge of Medicaid, CMS/Medicare, CCS, DMHC and DHS a must.
- Application level understanding of HIPPA, and Privacy Act.
- Application level understanding of NCQA.
- Understanding of operations and the relationships between departments and functional areas.
- Comprehensive background in health services operations, including program development.
- 6 years’ experience in a medical setting.
- 5 years’ experience in a leadership position.
- Excellent understanding of operations in a managed care environment.
- Excellent written and verbal communication skills.
- Demonstrated leadership skills.
- Excellent work assessment and analytical skills.
About the area:
San Diego is a city on the Pacific coast of California known for its beaches, parks and warm climate. Immense Balboa Park is the site of the world-famous San Diego Zoo, as well as numerous art galleries, artist studios, museums and gardens. A deep harbor is home to a large active naval fleet, with the USS Midway, an aircraft-carrier-turned-museum, open to the public. San Diego is the eighth largest city in the US and the second largest city in California. It has emerged as a healthcare and biotechnology hub. San Diego is also home to a professional baseball team, the Padres. San Diego’s neighboring city south of the border, Tijuana, is home to a professional soccer team, the Xolos.
Community Health Group offers a competitive compensation and benefit package. Whether or not this position interests you personally, I would love to get your input.
Rosie Saenz, Executive Recruiter