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Chief Medical Officer – Health Plan
Presbyterian Healthcare Services. Serve as the senior physician executive for the health plan .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive clinical leadership in medical management, utilization management, and quality improvement within health plans. Possesses strong expertise in medical necessity review, regulatory compliance, and population health initiatives.
Highest-signal resume keywords
MD Or DO DegreeActive Medical License - New MexicoBoard Certification10+ Years Clinical Leadership ExperienceManaged Care Leadership Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity ReviewClinical Criteria DevelopmentQuality ImprovementUtilization ManagementPopulation Health ManagementRegulatory ComplianceClinical GovernanceCase ManagementHEDIS/Stars Quality ProgramsBehavioral Health Integration
Soft Skills
Executive CommunicationPhysician LeadershipBusiness AcumenInfluence Skills
Certifications & Qualifications
CPHQCPE
Industry Keywords
Managed CareHealth PlanMedical DirectorQualityRegulatory RequirementsMedicare AdvantageMedicaidValue-Based CareIntegrated Delivery SystemNCQA
About the role
Key responsibilities & impact- Serve as the senior physician executive for the health plan
- Lead all Medical Directors and UM staff members, including clinicians and other clinical staff reviewers
- Provide clinical leadership across affordability, quality, utilization, access, member outcomes, population health, and provider engagement
- Advise executive leadership on clinical risk, utilization trends, medical cost drivers, medical policy, provider behavior, and quality improvement opportunities
- Represent the health plan in physician, provider, regulatory, and delivery system forums
- Serve as the accountable clinical leader for UM medical necessity decision-making
- Oversee adverse determinations, peer-to-peer review, appeals, reconsiderations, clinical escalation pathways, and physician reviewer consistency
- Ensure UM decisions are evidence-based, timely, fair, well-documented, and aligned with applicable requirements
- Maintain clinical oversight of criteria, medical necessity rationale, denial language, decision consistency, and reviewer performance
- Partner with the Healthcare Value Leader to ensure UM operations support timely and compliant clinical decisions
- Own clinical governance for medical policies, clinical criteria, practice guidelines, and evidence-based care standards
- Provide clinical leadership for coverage policy interpretation, new technology review, and emerging clinical practice changes
- Provide clinical guidance for case management, disease management, transitions of care, high-risk member programs, and population health initiatives
- Participate in complex case escalation, avoidable utilization review, post-acute strategy, and clinical intervention design
- Review medical cost and utilization trends with the Healthcare Value Leader, Finance, Actuarial, Analytics, and Network
- Lead initiatives related to inpatient utilization, ED utilization, post-acute care, specialty variation, site-of-care optimization, pharmacy trends, and avoidable admissions
- Support development of clinical interventions that reduce unnecessary utilization while preserving access and quality
- Serve as the health plan’s senior clinical representative to physicians, provider groups, and delivery system leaders
- Lead physician-to-physician conversations on medical necessity, utilization variation, care standards, documentation, quality improvement, and value-based performance
- Support provider education related to clinical criteria, medical policies, UM expectations, appeals, and evidence-based practice
- Partner with Quality, Behavioral Health, and Risk Adjustment leadership on clinical strategy, quality, risk adjustment, behavioral health integration, equity, accreditation, and regulatory requirements
- Provide clinical support for HEDIS, Stars or equivalent quality programs, care gap closure, chronic disease management, and clinical quality initiatives
Requirements
What you’ll need- MD or DO from an accredited medical school
- Active, unrestricted medical license – New Mexico
- Board certification
- 10 or more years of relevant clinical and health care leadership experience
- Managed care, health plan, medical director, UM, quality, population health, or medical management leadership experience
- Experience with medical necessity review, appeals, peer review, clinical criteria, medical policy, and regulatory/accreditation requirements
- Strong physician leadership, executive communication, business acumen, and influence skills
- Prior experience as a health plan CMO, deputy CMO, associate CMO, or senior medical director (preferred)
- Experience in Medicare Advantage, Medicaid, commercial health plan, provider-sponsored health plan, or integrated delivery system (preferred)
- Experience with NCQA, URAC, CMS, state regulatory requirements, HEDIS/Stars, value-based care, behavioral health integration, and risk adjustment (preferred)
- Advanced degree such as MBA, MHA, MPH, MMM, or equivalent (preferred)
- CPHQ, CPE, or equivalent physician leadership/quality credential (preferred)
Benefits
Comp & perks- Competitive salaries
- Full medical, dental and vision insurance
- Flexible spending accounts (FSAs)
- Free wellness programs
- Paid time off (PTO)
- Retirement plans, including matching employer contributions
- Continuing education and career development opportunities
- Life insurance and short/long term disability programs