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Chief Medical Officer

2 months ago

Lincoln, Nebraska, United States Highmark Health Full time


Highmark Health Chief Medical Officer

This position, as part of a collaborative physician team, is responsible for overseeing utilization management duties in alignment with the highest and most current clinical practices.

The selected candidate will evaluate complex cases electronically, utilizing Medical Policy criteria to assess the medical necessity and appropriateness of requested treatments or services.

Telephonic discussions with peers may be necessary depending on the complexity of the case. The role mandates strict adherence to NCQA, URAC, CMS, DOH, and DOL regulations at all times.

In addition to utilization management, the incumbent will serve as a physician member of the multidisciplinary team focusing on case and disease management.

They will provide guidance to the multidisciplinary team on cases, particularly those that are high-risk, through the established team structure. Furthermore, the incumbent may be tasked with special projects aimed at enhancing the care provided to our members.

KEY RESPONSIBILITIES

Conduct electronic evaluations of complex cases against medical policy criteria, which may involve telephonic peer discussions, to determine medical necessity and appropriateness.

Perform initial case determinations, review appeals and grievances, and handle other assessments as assigned.

Draft clear and concise rationales for member and provider determination notifications while ensuring compliance with required standards (NCQA, URAC, CMS, DOH, and DOL regulations, etc.).

Ensure that all elements of the medical management process align with community standards of care.
Participate as a member of the CMDM multidisciplinary team. Attend team meetings and case discussions. Provide expert advice on cases requiring physician input.
Engage in the development of protocols and guidelines to maintain consistency in the review process.
Actively manage projects and/or contribute to project teams that necessitate a physician subject matter expert.
Other responsibilities as assigned.

EDUCATION
Required
Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
Substitutions
None
Preferred
Master's Degree in Business Administration/Management or Public Health

EXPERIENCE
Required
5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice)
Preferred
1 year in Medical Management within a Health Insurance Plan; strong knowledge of the managed care sector

LICENSES AND CERTIFICATION
Required
Medical Doctor or Doctor of Osteopathic Medicine (DO)
Board Certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards
Active medical state licensure required. Additional specific state licensure(s) may be necessary based on business needs.
Preferred
None

SKILLS
Critical Thinking
Case Management
Customer Service
Telephone Skills
General Computer Skills
Clinical Software
Managed Care
Language (Other than English)
None
Travel Required
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type:
Office-Based

Teaches / trains others regularly:
Occasionally
Travel regularly from the office to various work sites or from site-to-site: Rarely
Works primarily out-of-the office selling products/services (sales employees): Never

Physical work site required:
No

Lifting:
up to 10 pounds: Constantly
Lifting: 10 to 25 pounds: Rarely
Lifting: 25 to 50 pounds: Rarely

Disclaimer:

This job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title.

It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.


Compliance Requirement:

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.

In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct.

This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.


Pay Range Minimum:
$170,000.00

Pay Range Maximum:
$342,274.00


Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.

The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law.

Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

EEO is The Law
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( )
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