VP, Chief Medical Officer, Medicare

Job Description

Your Role

The VP, CMO, Medicare is accountable for providing medical oversight, expertise and leadership to ensure the delivery of affordable, quality healthcare services across all Medicare product lines (Individual, Group, PPO). The role requires strong partnerships with the General Manager of the Medicare team, the Quality team, the Encounter team, and Network Management and as applicable other cross-functional leaders/team who impact Medicare performance, and will require a deep connection and "oversight" of the UM and CM teams within BSC. In addition, the work can only be successful in close collaboration with the delivery system partners who are delegated for certain clinical and administrative functions. As such, the VP CMO, Medicare will need to have strong skills in influencing, leading by example to establish, maintain and support provider partnerships, with insights and experiences in both health plan and delivery system infrastructure.

The VP CMO, Medicare will think strategically, have strong leadership and management skills, and be distinguished for the ability to achieve results and quality outcomes. The ideal candidate will have a successful track record of clinical oversight and outcome based performance, understand critical components of accurate and timely submission of risk scores through encounter data, Medicare revenue and costs related to utilization management, case management, pharmacy management, Medicare Stars experience, general health plan knowledge and firsthand experience implementing clinical programs into delivery systems, and facilitation of good working relationships and management of IPA's, medical groups and integrated health systems.

Responsibilities

Your Work

In this role, you will:

Engage Key Delivery System Partners

• Proactively engages with key delivery system partners to influence care delivery and to remove barriers to efficient, high-quality care for BSC Medicare members. These relationships include:
• Hospital leadership such as a Vice President for Medical Affairs, Chief of Medical Staff, Hospitalist group leader, Emergency Department director, or service line chairs to address areas of opportunity to reduce admissions and/or improve timeliness and success of discharges.
• IPA/Medical Group leadership including the Medical and UM Directors to address areas of outlier performance on key metrics such as hospital bed days and non-emergent ED utilization.
• IPA/Medical Group leadership including the Medical and Quality Directors to address areas of outlier performance on key metrics including HEDIS and CAHPS measures.
• These discussions shall be informed by data and lead to agreed-upon actions that will be tracked and completed.
• Work with internal Blue Shield of California partners
• Partner and collaborate with Medicare General Manager and team to ensure efforts are aligned with strategy and expected outcomes for the Medicare line of business.
• Partner with network contracting and participate in BSC meetings that design and implement Value Based Pay for Performance and other incentive plans to ensure consistency of messaging and optimization of behavior change in the delivery system.
• As part of the Regional Market Teams for Blue Shield of CA, partner with BSC Health Solutions peers including teams in utilization management, Medical Director concurrent review, ACO support, BSC Pharmacy and clinical quality improvement, among others.
• When needed, help resolve issues from BSC providers regarding case and disease management programs. Help resolve issues from other BSC teams with providers.

Implement Region-specific Strategy

• Lead the creation of a region-specific strategy and plan to achieve utilization and quality goals/targets.
• Develop a synchronized plan with the Network Management plan for business relationships with providers.
• Develop a synchronized plan with Quality to achieve Quality outcomes with providers.
• Responsible for monitoring the region-specific plan to ensure that the plan is executed as intended and periodically adjusting the plan as necessary, in order to achieve affordability, clinical quality, and member experience targets.
• Oversee, train, and hold accountable a team of Medicare Medical Directors and program managers to assist in carrying out the vision described above.

Qualifications

Your Knowledge and Experience

• Medical degree (M.D./D.O.)
• Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
• Active, unrestricted California State Medical License
• Minimum of 12 years of relevant experience required; including a minimum of 5 years managed care experience, and 5 years leading and managing staff
• Prior health plan experience, specifically as a Regional Medical Director
• Experience with Medicare Stars program (HEDIS, HOS, CAHPS)
• Experience with the Delegated Model
• IPA/Medical Group experience with >100,000 enrollees, including roles to influence practice change and to implement clinical intervention
• Clinical work in Internal Medicine, Family Practice, Pediatrics or emergency Medicine
• Understanding of the California marketplace
• Understanding of Accountable Care Organizations, and experience working in them
• Excellent verbal, written, presentation and group facilitation skills required, with the ability to convey complex or technical information in a manner that others can understand at all levels of the organization.
• Proven ability to develop and lead high performing teams
• Strong critical thinking skills required

About the Team

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

At Blue Shield of California, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:
  
  • Member-facing and approved out-of-state roles remain remote.
  • Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
  • For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.