South Carolina Medicaid CMO RVP Health Services

Profile

Description

The SC Medicaid CMO, RVP Health Services (CMO)relies on medical background to create and oversee clinical strategy for the region. The CMO requires an in-depth understanding of how organization capabilities interrelate across segments and/or enterprise-wide.

Responsibilities

Job Title: South Carolina Medicaid CMO, RVP Health Services

Location: Work from Home in South Carolina (with ability to commute to office in Columbia, SC as needed)

The CMO will provide medical leadership and strategy for the Health Services Operations with fiscal responsibility for trend management.

*Oversee regional utilization management and case management for inpatient cases (acute care hospital, LTAC, Acute rehab, SNF) according to the Humana's Medicaid policies and procedures.

*Participate in Quality Operations including chair Quality Management Committee, complete initial peer review on quality of care complaints, complete peer-to-peer written and verbal communications.

*Oversee administrative budget for regional HSO & Quality Improvement including approve/deny expense reports & requisition requests for department members.

*Oversee Quality Improvement and HEDIS/STARS metrics improvement with PCP offices and IPAs.

*Participate in regional level committees and meetings setting medical necessity strategies.

*Provide oversight and direction for the implementation of regional clinical programs and strategies, as well as, developing and implementing market level strategies.

*Manage internal operational/functional relationships related to profitability.

*Assist with network development and provider contracting with various providers and ancillary providers.

*Serve as clinical liaison with inpatient facilities and joint operating committees to maintain facility relationship and problem solve; especially reviewing contracts as to clinical services.

*Well-versed on financial aspects of various levels of risk bearing contracts and possess the ability to gain traction and adoption of the providers.

*Ability to thrive in a highly matrix environment.

Required Qualifications

*8 or more years of management experience

*A current and unrestricted license in at least South Carolina and willing to obtain license, as required, for various states in region of assignment

*MD or DO degree

*Board Certified in an approved ABMS Medical Specialty

*Excellent communication skills

*5 years of established clinical experience

*Knowledge of the managed care industry including Medicare, Medicaid, LTSS and or Commercial products

*Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, utilization management, discharge planning and/or home health or rehab

*Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

*Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc.


Experience working with the Medicaid population or Medicaid Managed Care, LTSS, PEDS, OB-GYN, Drug Abuse/Addiction, or Behavioral Health


*Master's Degree

#PhysicianCareers

Scheduled Weekly Hours

40

Company info

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