Staff VP, CMO Medicaid (hybrid)

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

This position requires work and residency within the state of Arizona.

Purpose of the job

The CMO/Medical Director shall actively provide oversight and management of the Quality Management, Quality Improvement, Maternal and Child Health, and Medical Management Programs within the Medicaid Segment; this includes direct oversight of the Adult and Children’s Healthcare Administrators and both physical and behavioral health services.  This position has overall accountability and oversight of all Medicaid Segment AHCCCS Health Plan clinical functions and medical cost trends consistent with the vision and strategy set forth by the senior executive leadership team to ensure medical policies, procedures, and activities/actions of the segment are consistent with standards of good medical practice in the community.  Actively involved in the shift towards a value-based, integrated delivery system in collaboration with strategic partners to ensure the delivery of the highest value healthcare services. This position is a key position within the AHCCCS contract and requires the incumbent to reside in the state of Arizona.

REQUIRED QUALIFICATIONS

Required Work Experience

• Minimum 5 years of clinical practice experience required
• Minimum 5 years of managed care experience required
• Minimum 5 years of experience with quality review, utilization review, and managed care functions
• Minimum 3 years of experience in developing short-and long-term range strategic plans, forecasting and budgeting
• Minimum 2 years NCQA experience

Required Education

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree

Required Licenses

• Active, current, and unrestricted license to practice medicine in the State of Arizona  

Required Certifications

• Board certified in their medical specialty required

PREFERRED QUALIFICATIONS

• Preferred Work Experience
• 10 years of management experience
• 10 years of clinical experience in a primary care field
• 10 years of experience with quality review, utilization review, and managed care functions
• 5 years of experience in developing short-and long-term range strategic plans, forecasting and budgeting

Preferred Education

• MBA or MPH

Preferred Licenses

• N/A

Preferred Certifications

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

• Provide direction, support and medical expertise and oversight to areas within the clinical services, including utilization management, quality management, case management, medical claims review, and pharmacy management. Specific activities include outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, precertification, medical claims reconsideration and retrospective review.
• Designs and implements the appropriate infrastructure and staffing resources under the Adult and Children’s Healthcare Administrators in order to ensure that expertise for both physical and behavioral health services are available and integrated within the organization
• Ensures compliance with all accreditation and regulatory regulations.
• Provide input and guidance for company quality management programs and policies including HEDIS, CAPHS, and quality complaints and reviews.
• Provide senior clinical oversight, guidance, and administration of the Care Management Program, Disease Management Program, Provider Network Management administration and Credentialing Program in accordance with NCQA and URAC Standards.
• Serves as the Medicaid clinical expert.
• Establishes credibility and rapport to collaborate with a broad set of senior executives, clinicians, local government leaders, and community representatives.
• Participates and supports the communication, education, and maintenance of partnerships with contracted providers, provider physician groups, and may serve as the interface between the Health Plan and providers, regulators, etc.
• Manages, mentors, and coaches a high performing leaders and team members that are focused on clinical quality, service excellence, and business literacy; accountable for the success of Medical Directors contributing to the AHCCCS Health Plan.
• Rallies support for t