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, Network Management, and other cross-functional leaders impacting Medicare performance. It also involves close oversight of the UM and CM teams within BSC. Success in this role depends on collaboration with delivery system partners delegated for clinical and administrative functions. Therefore, the VP CMO, Medicare must possess strong influencing skills and leadership qualities to establish and maintain provider partnerships, leveraging insights and experience from both health plan and delivery system infrastructures.
The VP CMO, Medicare should think strategically, demonstrate strong leadership and management skills, and be recognized for achieving results and quality outcomes. The ideal candidate will have a proven track record in clinical oversight, outcome-based performance, accurate and timely submission of risk scores through encounter data, Medicare revenue and costs management related to utilization management, case management, pharmacy management, Medicare Stars experience, and general health plan knowledge. Experience in implementing clinical programs into delivery systems and managing relationships with IPAs, medical groups, and integrated health systems is essential.
Your Knowledge and Experience
- Medical degree (M.D./D.O.)
- Completed residency, preferably in adult-based primary care specialties (e.g., internal medicine, family practice)
- Active, unrestricted California State Medical License
- Minimum of 12 years of relevant experience, including at least 5 years in managed care 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 over 100,000 enrollees, including roles in practice change influence and clinical intervention implementation
- Clinical work in Internal Medicine, Family Practice, Pediatrics, or Emergency Medicine
- Understanding of the California marketplace
- Knowledge of Accountable Care Organizations and experience working within them
- Excellent verbal, written, presentation, and group facilitation skills, capable of conveying complex information clearly at all organizational levels
- Proven ability to develop and lead high-performing teams
- Strong critical thinking skills