The Chief Medical Officer (CMO) Utilization Management will develop and manage efforts to improve and maintain cost and utilization trends. Responsible for URAC, NCQA, state departments of insurance, and similar accreditors/regulators for the performance of all utilization management (UM) programs across the enterprise. The CMO is individually responsible for overall clinical compliance within the UM programs, including matters concerning clinical policy, quality management (QM), program development, review of UM cases, clinical criteria, and provider issues, and always ensuring the clinical integrity and compliance of the programs.
Responsibilities and Essential Functions
- Responsible for development of clinical policy, clinical review decisions, appeals, audits, and other clinical functions, supported by program clinical leaders, and implement corrective actions when required.
- Oversee the company’s quality management program, including the development and implementation of internal quality monitors involving all operational areas of the organization and outcomes monitors focusing on potential over- and under-utilization of delegated services.
- Oversee clinical policy development via the Medical Advisory Committee (MAC), and facilitate collaboration across clinical programs to ensure optimal process and content harmonization.
- Collaborate closely with Compliance to ensure optimal performance at all audits conducted by NCQA, URAC, CMS, departments of insurance, or other outside regulators.
- Evaluate utilization trends, referral patterns, fraudulent medical practices, quality standards, regulatory changes, program performance, and client feedback, and recommend solutions for improvement where needed, supported by program clinical leaders.
- Set clinical strategy, planning, budgeting, and execution of annual goals for UM programs.
- Provide thought leadership regarding trends in clinical management to direct new product strategy.
- Provide executive clinical subject matter expertise (SME) for all UM strategic partnership opportunities related to UM services, which may include merger/acquisition activity.
- Lead a dynamic culture of open communication, transparency, and flexibility across all stakeholders that fosters empowerment and personal development of individual employees.
- Accountable for overall performance of all physician employees, including direct supervision of physician leaders in each UM program in close collaboration with business and operational leadership of the respective programs.
- Collaborate with Operations leadership to ensure optimal clinical quality and operational efficiency of all UM programs.
- Maintain strong relationship with clients’ medical leadership concerning clinical policy, quality, program development, clinical criteria, and provider issues, supported by program clinical leaders.
- Collaborate with the Analytics team to provide best-in-class analytics and reporting on UM trends and performance and, when necessary, recommend corrective actions concerning utilization trends, referral patterns, fraudulent medical practices and quality standards, supported by program leaders.
- Serve as executive clinical SME for sales presentations for new or comprehensive UM programs or services, supported by program clinical leaders.
- Provide SME support to Legal, Business, and Client teams for clinical matters related to UM client contracts.
- Review official program communications and reports to clients to assure uniformity and accuracy of policies and statistics, supported by program clinical leaders.
- Serve as public face of UM clinical programs, supported by program clinical leaders and Marketing, including representing at key professional meetings, as a presenter when appropriate.
- Lead efforts to enhance the company’s brand as an evidence-based medicine leader through peer-reviewed presentation and publication of new knowledge generated by UM programs, supported by program clinical leaders.
- Establish informal and formal mechanisms to promote and maintain credibility, competence and positive corporate image by exhibiting strong communication to clients, corporate, providers, committees, and employees.
- Provide executive clinical SME to support Legislative Affairs efforts, professional society collaborations, provider partnerships, and other clinical collaborative efforts with external stakeholders.
- Other related duties as assigned.
Critical Experiences
- Value Based Care: Transitioning healthcare delivery models toward value-based care, emphasizing outcomes and cost effectiveness.
- Enterprise Value Creation: Aligning a set of clinical metrics/outcomes with direct linkage to enterprise value creation and member health, to create a clear mandate and accountability that prioritizes high-value areas.
- Scaling Commercial Solutions: Overseeing the end-to-end development and scaling of healthcare solutions. Driving innovation through the implementation of technologies and care models.
- Thought leadership and clinical face to market: Engaging with diverse external stakeholders in the community to stay informed and shape the latest clinical and policy developments. Serving as the clinical face outside the organization to help inform and validate decision-making processes and provide insight that supports the business development lifecycle. Fostering collaborations to enhance care delivery and contributing to discussions in the public policy arena.
- Clinical leadership: Serving as the highest point of clinical leadership. Having end to end oversight of the clinical model (including P&L) for all programs and care delivery businesses and ensuring a high-quality patient care culture is created. Balancing clinical choices with business outcomes to gain market traction and deliver on financial results.
- Clinical strategy: Articulating a clinical vision for the business. Leading and shaping the development of forward-looking strategies that align with overarching enterprise objectives. Operationalizing the clinical vision and identifying opportunities for improvement that balance profitable business and clinical outcomes (e.g., patient outcomes, cost containment and quality of healthcare services).
- Strategic business partner: Having a partnership role in business with internal and external audiences such as key opinion leaders, advisory boards and regulators, to promote and advance business solutions and address areas of concern. Presenting to these audiences may occur in forums such as conferences, board meetings, public hearings, and media appearances.
- Transformation & change: Leading a change initiative in a complex matrixed environment (e.g., transformation of ways of working / processes, vision / priorities / culture and technology application, etc.). Managing transformation through practices such as: creating a vision and purpose, frequent and timely communication, leadership alignment, stakeholder engagement, educating / training the organization, and overcoming resistance.
- Building Next Generation Clinical Talent: Having direct people management responsibility for a team through the full talent lifecycle: attracting, hiring, onboarding, developing, managing performance, and promoting talent, as well as exiting team members when necessary.
- Compliance, Safety and Quality Care: Cultivating a culture and fostering practice across the care delivery teams that prioritize high quality, safe and compliant operations within the Healthcare Sector.
Competencies for Success
- Strategic Mindset
- Cultivates Innovation
- Instills Trust
- Courage
- Ensures Accountability
- Persuades
- Drives Results
- Drives Engagement
- Communicates Effectively
Traits to Enable Success:
- Intellectual curiosity
- Optimism
- Motivated to Win
- Humility
- Assertiveness
- Openness
- Persistence
- Thrive In Ambiguity
- Affiliation
Key Drivers
- Collaboration - A preference for work-related interdependence, group decision making, and pursuing shared goals.
- Challenge - Motivated by achievement in the face of tough obstacles.
- Ambition - Motivated to seek influence, recognition and increasing levels of responsibility.
Physical Demands/Environmental Factors
- Requires extensive sitting with periodic standing and walking.
- May be required to lift up to 20 pounds.
- Requires significant use of personal computer, phone and general office equipment.
- Needs adequate visual acuity, ability to grasp and handle objects.
- Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.
- May require off-site travel.
Minimum Qualifications
- M.D. or D.O. degree from accredited institution.
- 10+ years managing people and large-scale enterprise projects/initiatives.
- 10+ years in the health care industry, experience in a UM organization a plus.
- Knowledge of applicable state and federal laws, URAC and NCQA standards, and utilization management.
- Excellent Microsoft Office skills, with PowerPoint and visual presentation skills on par with what is expected for presentations to senior leaders.
- The ability to influence others through data, negotiation, and presentation.
- The ability to manage projects to schedule and within budget.
- An intellectual curiosity, be enterprising by nature and blend ingenuity with business acumen.
- A strong bias for action.
- A broad understanding of the health care industry, enabling an ability to convey and align others around solutions.
- Experience taking ideas/concepts to proof of concept/pilots.
- Experience with diverse teams.
- A belief in the power of teamwork and diverse thinking where collaboration is considered a must for delivering the greatest success.
- An open mind, a positive attitude, and a sense of humor.
- A professional history that illustrates an ability to overcome challenges and deliver.
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
