Chief Medical Officer OhioRise

6 days ago

Columbus, Ohio, United States CVS Health Full time
Job Summary:

The Chief Medical Officer (CMO) is a key leadership position at CVS Health, responsible for overseeing medical policy implementation and participating in the development, implementation, and evaluation of clinical/medical programs. This role requires a strong clinical background and experience in healthcare delivery systems.

Key Responsibilities:

Leads, develops, directs, and implements clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
Directs the utilization review process and oversees the quality of utilization determinations.
Ensures compliance with clinical goals through monitoring care management performance.
Responsible for overall medical policies of the unit to ensure the appropriate and most cost-effective medical care is received, and for the day-to-day management of medical management staff.
Develops, implements, and interprets medical policy, including medical necessity criteria, clinical practice guidelines, and new technology assessments.
Leads clinical staff in the coordination of quality care.
Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.
Expands Aetna's medical management programs to address member needs across the continuum of care.
Provides thought leadership for quality initiatives for the plan.

Specific to the OhioRISE Contract:

Ensures that the OhioRISE Plan makes timely medical decisions, including after-hours consultation as needed.
Leads all major clinical, population health management, and quality improvement components of the OhioRISE Plan.
Develops, implements, and interprets medical policies and procedures, including service authorization, claims review, discharge planning, and medical reviews performed through the OhioRISE Plan's grievance and appeal system.
Leads the administration of all medical management activities of the OhioRISE Plan.
Serves as the chair or co-chair of the Utilization Management committee and of the OhioRISE Plan's internal quality improvement committee.
Plays a lead role in monitoring the overall safety of members with complex and/or comorbid medical conditions.
Coordinates with the MCO's care management staff and providers on medical services not included in the OhioRISE Plan's service array, early and periodic screening, diagnostic and treatment (EPSDT), receipt of maternal and postpartum care, family planning, and preventative health strategies.
Serves as a key clinical lead in developing and implementing evidence-based clinical policies and practices;
Participates in regulatory/accreditation reviews.
Works with MCO's clinical leadership as needed for integration of all healthcare needs and services for OhioRISE Plan's members.
Assumes a key role in quality improvement initiatives, care coordination activities, and member safety activities (i.e., incident management).

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