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Position Summary
The ABHMI CMO will serve as a strategic and operational partner to the Health Plan CEO, COO, CFO and other executive team members in Medicaid driving clinical excellence, achieving measurable health outcomes, and supporting quality and medical management in a highly matrixed environment. The CMO will also support national strategic processes and priorities as well as conceptualization, design, and implementation of strategic priorities for Medicaid. The State CMO will be responsible for cost containment outcomes and defined KPI’s and overall growth and success of the plan through effective clinical leadership.
- Accountable for overall plan results and the delivery of high-quality cost-effective products and services that strategically align to the goals of the State partner.
- Ensures members get the right health care treatment for their needs, working to eliminate low value care, over and underutilization of health care services in alignment with the Quintuple AIM.
- Participates with plan leaders in identification and developing the appropriate enterprise and local strategies to fulfill plan business goals and growth imperatives.
- Provide clinical expertise to shape the integrative model of physical, behavioral, and health related resource needs to support holistic care and optimal health outcomes.
Primary Job Duties & Responsibilities
- Develop, implement, support, and promote population health strategies, tactics, policies, and programs that drive the delivery of high value healthcare to establish a sustainable competitive business advantage by supporting the plan goals.
- Review, interpret and analyze data and trends at State level in: UM, CM, Pop Health and Health Equity in order to identify risks and opportunities for improvement
- Serve as clinical executive leader for State regulators, providers, and other key partners. Serve as clinical leader for provider engagement and enablement.
- Have oversight of the design, development, and deployment of Care Models and review medical care provided to Enrollees and medical aspects of the Provider Contract.
- Ensure clinical programs are compliant with all national and state regulations including ensuring compliance with State and local reporting laws on communicable diseases, Child Abuse, and neglect
- Oversight of the Quality Assessment and Performance Improvement Program (QAPI)
The CMO Is a Member Of The Plan Executive Leadership Team And Must Collaborate Cross Functionally To Achieve Plan Goals Including
- Serving as a subject matter expert and provide oversight of the design, development, and deployment of Care Management, Utilization Management, Population Health, Health Equity and Quality programs.
- Collaborating with the Medical Management stakeholders both internally (UM/CM, Pharmacy, Quality, network, compliance, VBS team) and externally (Agency, regulators, providers, community partners) ensuring timely and consistent responses to the needs of members and providers.
- Coordinate with the Population Health Management Director and provide clinical leadership on population health.
- Building and inspiring a culture of continuous improvement for better quality of care measured by improving HEDIS/STARS outcomes and supporting appropriate utilization of services. Work closely with Quality, Health Equity, and BH integration teams with shared accountability for overall quality outcomes that improve plan ranking among competitors, support compliance activities and support accreditation activities.
- Supporting the UM team in predetermination reviews and providing clinical, coding, and reimbursement expertise. Work closely with UM team and Plan clinical leaders to identify and effectively manage emerging utilization trends, large case reviews, and out of state service requests.
- Serving as the clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams. Support management of medically complicated care and lead collaboration internally and externally to support coordinated care.
- Partnering with Plan leaders, Network, and provider relations teams to drive differentiated provider engagement/experience. Collaborate with network teams to optimize provider performance, value based arrangements, and strategically expand VBS network.
- Exhibiting strong business acumen. Understands and proficient in sharing financial impacts, and market demands. Ability to understand and interpret data (e.g., medical cost trends) and articulate trend and solutions. Use data analytics to inform and influence population health to drive behavior change and expand Aetna's medical management programs to address specific member conditions across the continuum of care. Partner with all Health Plan based and enterprise leaders to monitor and mitigate emerging cost drivers (MED/ BH/ Rx).
- Serving as an externally facing brand ambassador; inform and influence all constituents (e.g., providers, state regulators, community, and faith-based organizations). Strong oral and written communication skills in presenting to varied groups including providers, state and local agencies, key stakeholders (community-based organizations, and advocacy groups).
- Collaborating and partnering with Social Impact teams to develop strategy to identify, engage, and improve the lives of members identified with known or potential health related resource needs.
- Collaborating with and provide subject matter expertise to the product team to arrive at new and innovative products that help achieve business goals.
- Ensure compliance with State and local reporting laws on communicable diseases, child Abuse, and neglect.
Required Qualifications
At least five years’ experience in the health care delivery system e.g., clinical practice and health care industry.
At least three years of experience Medicaid and managed care experience.
Must be a physician with a current, unencumbered license through the state of Michigan.
Board Certification in a recognized specialty including post-graduate direct patient care experience.
Preferred Qualifications
- Demonstrated experience in population health management and Managed Care.
- Passion and ability to influence and drive better outcomes in healthcare delivery.
- Understanding of Value Based Contracting/Accountable Care and how this relates to improving the quality of care for our members through collaboration with the provider community.
Education
MD or DO Required Board Certification required in an ABMS or AOA recognized specialty.
Pay Range
The Typical Pay Range For This Role Is
$184,112.00 - $396,550.00
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great Benefits For Great People
We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 08/29/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
