Chief Medical Officer

ESI is looking for a Chief Medical officer with our client in North Palm Beach county.

The Chief Medical Officer oversees all clinical management and services of the organization, which includes ensuring regulatory compliance, managing health services team, and being the medical expert for making strategic decisions for the organization. The goal of the CMO is to play a key role in driving quality outcomes and be an advocate for the ACO Reach program.

Essential Job Function

• Develop, plan, and implement medical strategies aligned with the organization's ACO Reach program goals and objectives.
• Oversee and guide health services team on ensuring high-quality results in ACO Reach program.
• Ensure compliance with relevant medical regulations, standards, and guidelines for structure and implementation of compliance audits.
• Regularly reviews clinical performance of Participant Providers and Preferred Providers as defined in the ACO REACH program as well as ancillary providers such as hospitals, health systems, specialists, etc.
• Reviews and reports on patient data analytics including (a) medical record and billing reviews, (b) training for Participant Providers and their staff as well as Employer's administrative team regarding medical and billing record preparation and reporting,
• Undertakes quality assurance or utilization reviews whether prospective, retrospective, or concurrent, and (d) advise and supervise regarding inpatient and outpatient coding including Healthcare Effectiveness and Data and Information Set ("HEDIS") measurement and reporting, Medical Loss Ratio("MLR") measurement and reporting, Hierarchical Condition Category Coding ("HCCC") measurement and reporting, Diagnosis Related Group (''DRG") and Current Procedural Terminology ("CPT") measurement and reporting, (g) International Classification of Diseases, Clinical Modification ICD-10-CM/PCS ("ICD l0") measurement and reporting-each as may be amended or supplemented from time to time or as otherwise required by the ACO REACH Program.
• Collaborate and show initiative in integral leadership meetings and organize reports for board meetings.
• Develops and presents educational programs on behalf of Employer regarding Minimum Clinical Measures.
• Advocates on behalf of Employer as a participant in the ACO REACH Program; and Regularly reviews adequacy of documentation to support diagnoses (validation) consistent with the Minimum Clinical Measures.
• Identifies opportunities to improve identification and management of conditions for ACO REACH beneficiaries
• Identifies and reviews with Participant Providers patient conditions lacking adequate management: Undertakes corrective action and regularly report on clinical management activities as directed by CEO.
• Identify and mitigate risks for claims adjudication, pharmacy utilization management, case management review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing, and profiling.
• Regularly reviews Participant Provider operations and reporting which review anticipates in-person travel by Chief Medical Officer.
• Prepares and updates disease screening-identifying potential conditions the company should screen for and identify using different modalities and assist in the development of a chronic disease treatment program.
• Reviews and monitors referral requests by Participate Providers and self-referrals by ACO REACH beneficiaries. When appropriate, actively participate in related education and training about alternative approaches to avoid requirements for referral or to improve results from referrals.
• Maintains up-to-date knowledge of new information and technologies in medicine and their application.
• Recommends changes in program content in concurrence with changing markets and technologies.
• Provides professional leadership and direction to the Employer's operations with particular emphasis on Employer's Medical Management and Reporting activities (Utilization/Cost Management/Clinical Quality Management and related reporting to CMS).
• Collaborates with other senior managers in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.

Knowledge, Skills and Competencies

• Strong background in healthcare leadership, policy development and execution as well as relationship management.
• Strong understanding of utilization management as well as standard utilization and financial metrics.
• Strong ability to analyze utilization and communicate with providers regarding gaps in care and provide suggestions and solutions.
• Familiarity with accountable care organizations.
• Strong understanding of population health management and the ability to apply concepts to physician practice improvement.
• Strong ability to communicate provider performance based on our measurements and identify opportunities to consider change.
• Ability to problem solve to formulate a plan of care and evaluate the patient's response to care.
• Microsoft Office including Word, Excel and PowerPoint

Education and Experience

• Doctor of Medicine or Doctor of Osteopathy from an accredited medical school
• Current state medical license and in good standing with medical board
• 15 years in primary care, family medicine, or comparable specialty
• 7 – 10 years of Medical Director or similar leadership experience in primary care.
• Experience with data analytics programs and reporting.
• Experience in practice transformation as it pertains to the “Triple Aim”; reduction of the per capita cost of care through quality care and improved patient experience.