Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Job Summary
The Chief Medical Officer (CMO) has accountability for the clinical strategy for Medical Affairs, Quality, and Medical Management all while building sustainable programs that promote innovative ways to achieve improved outcomes for our members. These responsibilities include care management oversight, quality/STAR rating improvements, appropriate utilization, health system transformation and implementation of medical programs/policies, enhancing relationships with providers and facilities, industry policy advocacy, and regulatory agencies. Collaborates with the Executive Leadership Team (ELT) and key contributors to drive and implement strategies to support Community's mission and vision. The CMO will act as the external Clinical Leader for Community Health Choice and must be willing to travel locally and throughout the state as needed. Responsible for driving excellent results for all clinical affordability, quality, population health, growth, Net Promoter Score, and external relationship initiatives. Additional plan medical directors, pharmacy, quality, and others report to this position. The Chief Medical Officer reports to Community's CEO.
JOB SPECIFICATIONS AND CORE COMPETENCIES:
Provides clinical oversight of Care/Disease Management and Population Health programs:
a. Active participant in various Community Executive Committees including Quality, Compliance, and others as appropriate. Participates in Quality Improvement (QI) activities.
b. Collaborates with Leadership of the Quality function in the design and implementation of specific QI studies and initiatives.
c. Provides reports to Executive Leadership and the Board of Directors on Clinical Protocols and Quality Improvement activities.
d. Leads in development of Clinical protocols, risk-stratification, and policies based on evidence-based medicine and best practices.
e. Assists in development and review of patient materials and education
activities related to CM/DM programs.
Provides clinical expertise for utilization management, care/disease management and care coordination programs. In collaboration with leadership of Care Management, the CMO:
a. Ensures that utilization decisions are based upon medical necessity, benefit plan, and utilization of approved care guidelines and protocols.
b. Coordinates in-house rounding to review and educate using real time cases.
c. Reviews, updates, and creates clinical policies as needed to ensure Care Management compliance with applicable standards and regulations.
d. Reviews and analyzes data and makes recommendations to the Care Management Leadership on ways to appropriately reduce medical expenses.
e. Responds to regulatory requests, complaints and appeals regarding UM issues as necessary.
Provides clinical oversight of accreditation functions:
a. Develops and reviews department policies and procedures to ensure compliance with regulatory and accrediting entities.
b. Develops and participates in peer review programs for providers that ensures the delivery of quality of care.
c. Provides clinical support as needed for delegated entity and accreditation activities.
d. Provides direct peer-to-peer discussions with Network Providers regarding specific cases as well as general protocols.
Responsible for planning, coordinating, and supervising medical management operations.
Represents CHC at community events, with the media, regulatory agencies, trade associations and other public activities. Participates in professional organizations and community activities that promote positive relationships.
Provides training and oversight to other medical directors providing similar peer-to-peer discussions.
Assists Network and Provider Operations developing programs for physicians, other providers, and members to provide orientation to the health plan, health education, provider education and feedback. Assists with provider contracting issues when appropriate.
Develops annual departmental budget and monitors expenditures to meet administrative cost targets.
MINIMUM QUALIFICATIONS:
Education/Specialized Training/Licensure:
MD Degree or DO and Licensure in the State of Texas, Completion of Residency and Board Certification in Family Medicine, Internal Medicine, Pediatrics or OB/GYN with preference for the Primary Care Specialties required.
Work Experience (Years and Area):
12 years clinical experience with 5 years of administrative experience in managed care, including management of other physicians and/or clinical staff; master's degree in public health, business administration or medical administration preferred.
Management Experience (Years and Area): 5 years of administrative experience in Health plan management, including management of other physicians and/or clinical staff.
Software Proficiencies: Microsoft Office (Word, Excel, Outlook and PowerPoint)
