Chief Medical Officer--Aetna Better Health of Michigan

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Position Summary

The ABHMI CMO will serve as a strategic and operational partner to the Health Plan CEO, COO, CFO and other executive team members in Medicaid driving clinical excellence, achieving measurable health outcomes, and supporting quality and medical management in a highly matrixed environment. The CMO will also support national strategic processes and priorities as well as conceptualization, design, and implementation of strategic priorities for Medicaid.  The State CMO will be responsible for cost containment outcomes and defined KPI’s and overall growth and success of the plan through effective clinical leadership.
1.    Accountable for overall plan results and the delivery of high-quality cost-effective products and services that strategically align to the goals of the State partner. 
2.    Ensures members get the right health care treatment for their needs, working to eliminate low value care, over and underutilization of health care services in alignment with the Quintuple AIM.
3.    Participates with plan leaders in identification and developing the appropriate enterprise and local strategies to fulfill plan business goals and growth imperatives. 
4.    Provide clinical expertise to shape the integrative model of physical, behavioral, and health related resource needs to support holistic care and optimal health outcomes.

Primary Job Duties & Responsibilities

1.    Develop, implement, support, and promote population health strategies, tactics, policies, and programs that drive the delivery of high value healthcare to establish a sustainable competitive business advantage by supporting the plan goals.
2.    Review, interpret and analyze data and trends at State level in: UM, CM, Pop Health and Health Equity in order to identify risks and opportunities for improvement
3.    Serve as clinical executive leader for State regulators, providers, and other key partners.  Serve as clinical leader for provider engagement and enablement.  
4.    Have oversight of the design, development, and deployment of Care Models and review medical care provided to Enrollees and medical aspects of the Provider Contract.
5.    Ensure clinical programs are compliant with all national and state regulations including ensuring compliance with State and local reporting laws on communicable diseases, Child Abuse, and neglect
6.    Oversight of the Quality Assessment and Performance Improvement Program (QAPI)

The CMO is a member of the plan executive leadership team and must collaborate cross functionally to achieve plan goals including:
1.    Serving as a subject matter expert and provide oversight of the design, development, and deployment of Care Management, Utilization Management, Population Health, Health Equity and Quality programs. 
2.    Collaborating with the Medical Management stakeholders both internally (UM/CM, Pharmacy, Quality, network, compliance, VBS team) and externally (Agency, regulators, providers, community partners) ensuring timely and consistent responses to the needs of members and providers. 

3. Coordinate with the Population Health Management Director and provide clinical leadership on population health.

4.    Building and inspiring a culture of continuous improvement for better quality of care measured by improving HEDIS/STARS outcomes and supporting appropriate utilization of services. Work closely with Quality, Health Equity, and BH integration teams with shared accountability for overall quality outcomes that improve plan ranking among competitors, support compliance activities and support accreditation activities.
5.    Supporting the UM team in predetermination reviews and providing clinical, coding, and reimbursement expertise. Work closely with UM team and Plan clinical leaders to identify and effectively manage emerging utilization trends, large case reviews, and out of state service requests.
6.    Serving as the clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams. Support management of medically complicated care and lead collaboration internally and externally to support coordinated care.
7.    Partnering with Plan leaders, Network, and provider relations teams to drive differentiated provider engagement/experience. C