Company :Gateway Health Plan
Job Description :
Gateway Health sees a future where everyone has equal opportunity to achieve their best health. We are committed to the Wholecare of each of our members and believe Behavioral Health is foundational to achieving our mission of caring for the whole person in all communities where the need is greatest. The Chief Medical Officer is as a key member of Gateway Health LLC’s leadership team, and is a leader in the embodiment and sustainment of “wholecare” for Gateway’s members. The incumbent develops the vision, strategies and supporting plans to execute on initiatives to improve health outcomes in the communities Gateway Health serves. This will include a focus on health plan quality, medical policy, utilization management transformation, social determinants of health, health disparities, and health informatics to effectively address patients’ social, physical, and mental health needs. Will link with executives within our organization and across the nation to discuss and influence strategies, plans and communications. The incumbent plays an important role in overall corporate planning and strategic positioning at the most senior level and acts as an important public face for Gateway, presenting the Organization’s views to federal, state, and local government agencies, local business coalitions, organized medicine, national business and clinical associations, providers, etc.
- Develops a medical point of view for Gateway Health LLC. and provides medical leadership to the executive team. Utilizes medical expertise on critical business decisions.
- With Gateway leadership, assure strategic alignment for Medicaid, LTSS, CHC and D-SNP with corporate strategy; partners with executive leadership to develop overall vision, strategic plans and build operational excellence to grow Gateway business across the State and beyond. Support all lines of business related to Medicaid, Medicare (D-SNP) and future business such as CHC and LTSS.
- Works closely with organization and enterprise leaders for the purposes of strategic planning and operationalizing initiatives. Works with this team to evaluate and analyze corporate strengths, develop management solutions.
- Engages externally with other payers, providers and regulatory bodies. Represents Gateway Health LLC. with medical societies and other Provider/Payer CMO’s.
- Identify opportunities and acts to collaborate with practitioners and facilities, regional and statewide collaborative, and other MCO’s (e.g., BHMCOs) to improve quality and cost-effective care.
- Lead and implement the clinical direction for the organization. Keep abreast of emerging models in health care delivery; identify and define new and innovative strategies to achieve business goals and objectives.
- Identify opportunities and acts to collaborate with practitioners and facilities DPW, regional and statewide collaborative and other MCO’s (e.g., BHMCOs) to improve quality and cost effective care.
- Work with community agencies and other organizations to identify, implement and support programs aimed at improving the social determinants of health for Gateway members and the communities where we serve.
- Collaborate and partner with key physician leaders at Highmark and Allegheny Health Network.
- Provide clinical oversight to compliance activities, and assists operations/programs to comply with accreditation and regulatory standards, including but not limited to NCQA, DHS, CMS, etc.
- Oversees all of Health Plan medical quality, as mandated by both governmental and accreditation programs. This includes oversight over all medical decision-making, readiness and medical accreditation programs (NCQA, URAC, CMS, and other organizations).
- Provides oversight over all clinical quality activities, including all functions within the Quality Management Area. Functions include creation, development and implementation for all Quality Improvement related activities.
- Drives corporate policy and process for medical providers to effectively manage and control medical claims cost, including the assurance that all claims are processed in compliance with and according to contract provisions and regulatory requirements.
- Leverages data, clinical guidelines, and technology to enable the right care at the right time and improve the health of our population. This includes, in partnership with a variety of internal and external leaders, overseeing work to advance the development of systems of care to effectively address patients’ health disparities and SDoH. Influences and guides the overall health disparity strategy and health measures as well as leverages multiple individual components and capabilities to develop appropriate interventions to close disparity gaps. Establishes clinical informatics process models and strategies to seamlessly integrate automated and scalable clinical decision support into clinician and member/patient workflows.
- Leads the strategic planning to transform utilization management with the goal of reducing the administrative burden on providers and eventually automating authorizations.
- Performs management responsibilities including, but not limited to: involved in hiring and performance decisions, coaching and development, rewards and recognition, performance management and staff productivity.
- Plan, organize, staff, direct and control the day-to-day operations of the department; develops and implements policies and programs as necessary; has budgetary responsibility and authority.
- Other duties as assigned or requested.
- Bachelor’s degree in or equivalent training in an undergraduate college degree and all pre-med requirements
- Doctor of Medicine (MD) or Osteopathy (DO)
- 5-10 years in Clinical Practice of medicine
- 7-10 years in medical management activities
Licenses or Certifications
- Completion of Annual CME requirements to maintain medical licensure (50/year or more, or AMA Physician Recognition Award Recognition)
- Completion of Biannual CME requirements in risk management as mandated by Pennsylvania MCARE Act
- Board certification in a primary medical specialty and a current, unrestricted PA medical license is required. Mandated by state law for Pennsylvania and other state UM requirements
- Professional UR/QI training and certification
- Formal advanced training in management, such as a master’s degree in business administration, a master’s in health care management or administration, or similar degree
- Quality Assurance and Utilization Review – such as the ABQAURP boards
- Ability to understand complex medical issues involved in advanced medical decision-making, clinical contracting, and policy development
- Medical staff leadership experience, significant prior experience in health care management roles, and involvement with formal quality and utilization management programs are required
- 5 years of experience as a primary care physician or other valuable medical expertise and current knowledge of the clinical practice concerns and issues
- Proven ability to manage a project in order to accomplish previously agreed upon desired goals within a reasonable time period and through the use of developed organizational and leadership skills
- Excellent communication and public speaking skills, well-developed interpersonal skills, and the ability to interact effectively with members, practitioners/providers, colleagues, and local state and federal agencies.
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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