Blue Shield Of California
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
Your Knowledge and Experience
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. 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 achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!
Our Values:
At Blue Shield of California and the Ascendiun Family of Companies, 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:
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.
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.
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.
- 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.
- Additionally, this role will serve as a key physician leader within the Chief Medical Officer organization, flexing to the needs of the business and supporting the Chief Medical Officer in areas such as Population Health Management, Medical Policy, Medical Management, and any other areas where their clinical expertise may be needed to support the organization.
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 Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. 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 achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. 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 listen and communicate effectively, showing empathy by understanding others' perspectives.
- Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
At Blue Shield of California and the Ascendiun Family of Companies, 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:
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.