Chief Medical Officer - Health Plan; Hybrid or Remote

Location Address: 9521 San Mateo NE Albuquerque, NM

Summary:

The Chief Medical Officer is the senior physician executive responsible for the health plan’s clinical leadership, medical policy, clinical strategy, utilization management decision authority, medical necessity oversight, appeals, peer-to-peer review, and provider clinical engagement. In the refreshed model, the CMO should hold explicit accountability for UM decision responsibility, including medical necessity determinations, adverse determinations, clinical escalation, appeals, peer-to-peer review, and governance of medical criteria.

The CMO should not be positioned as the primary operator of all UM and CM workflows. Those should sit with the Healthcare Value Leader. This is consistent with external health plan CMO benchmarking, where the CMO provides leadership for care management and utilization management programs, oversees appropriateness and medical necessity, develops clinical practice guidelines, leads medical cost/utilization analysis, and directs medical management decisions.

• Remote:
  Open to applicants in the United States, excluding CA, IL, ND, NY, OH, WA, and WY.
• Hybrid:
  For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday.

• 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 federal, state, accreditation, and plan 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.
• NCQA’s UM framework emphasizes objective, evidence-based criteria, relevant clinical information, qualified professionals, fair and timely decisions, and appropriate appeals handling.

• Own clinical governance for medical policies, clinical criteria, practice guidelines, and evidence-based care standards.
• Ensure policies are current, clinically appropriate, compliant, and operationally implementable.
• Partner with Compliance, Legal, Quality, Pharmacy, UM Operations, Network, and the Healthcare Value Leader on policy updates and implementation.
• Provide clinical leadership for coverage policy interpretation, new technology review, and emerging clinical practice changes.

• Provide clinical guidance for complex case management, disease management, transitions of care, high-risk member programs, and population health initiatives.
• Support the clinical design of care management programs while the Healthcare Value Leader owns operational execution.
• Participate in complex case escalation, avoidable utilization review, post-acute strategy, and clinical intervention design.
• Collaborate with CM Operations to ensure programs are…