Job Description

Job Title: Chief Medical Officer

Location: Birmingham, AL (Reside in Birmingham or travel to Birmingham regularly)

Reports to: Chief Executive Officer

Associated Care Ventures Overview

ACV is a provider owned management company based in Birmingham, Alabama that is leading innovation in long term care. ACV has licensed a wholly owned insurance company named Simpra Advantage, Inc. (Simpra). Simpra, which is domiciled in Alabama, has a Medicare Advantage contract to operate three Special Needs Plans state-wide in Alabama, an Institutional Special Needs Plan, an Institutional Equivalent Special Needs Plan, and a Dual Eligible Special Needs Plan. There are presently 106 nursing homes participating in the Special Needs Plan. ACV has also formed a wholly owned subsidiary, Alabama Select Network, LLC, which contracts with Alabama Medicaid as an Integrated Care Network (ICN) to complement and enhance the current long-term services and supports (LTSS) system by introducing tools to better manage the medical and LTSS needs of Medicaid beneficiaries who qualify for HCBS waivers.

Role Summary

The ACV CMO is the Senior leader of ACV responsible for clinical direction of medical services, behavioral health services, utilization management, and quality improvement functions of the Medicare Advantage Special Needs Plans. The ACV CMO also serves as the Medical Director for Alabama Select Network.

Primary Responsibilities:

• Establish positive and pro-active working relationships with ACV owners and management at the corporate level regarding their participation in the Simpra Advantage Special Needs Plans. Provide guidance, reporting and insights on clinical performance of the Special Needs Plans.

• Establish routine and effective two-way communications processes with participants in the Special Needs Plans’ delivery of care including Nurse Practitioners, Primary Care and attending physicians, nursing home CMOs and nursing home Directors of Nursing and Administrators. Oversee provider education regarding pharmacy, hospital utilization, quality improvement and responsible health care expenditures to improve clinical outcomes.

• Provide current medical expertise and direction for clinical policies and programs. Effectively resolve complex, controversial or unique administrative circumstances related to execution of the Special Needs Plans’ models of care. Initiate dialogue with providers as necessary to resolve differences in opinions regarding utilization management and drug prior authorizations. Ensure that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management.

• Consult with Nurse Practitioners, Physicians, Behavioral Health providers and Pharmacists to expand primary care for long term residents in nursing homes.

• Conduct or observe interdisciplinary care team meetings on a non-scheduled basis to ensure that medical, pharmacological, behavioral and other service needs of Special Needs Plan beneficiaries are being met.

• Review emergency room utilization and hospital admissions of beneficiaries to identify opportunities to improve the quality of care and reduce avoidable hospital and emergency room utilization. Provide continuous feedback to participants in the Special Needs Plans’ delivery of care and identify and communicate trends and opportunities.

• Provide clinical oversight for service authorizations and conduct medical chart reviews as needed.

• Review clinical grievances, Potential Quality Issues (PQI), and Quality of Care Issues (QCI). Assign severity levels and direct follow-up which may include peer review and corrective action plans. Make determinations regarding provider appeals.

• Provide clinical leadership for the health plan Quality Program including implementation of the Quality Program, Annual Assessment of the Quality Program, an Annual Quality Work Plan and committee activities that support the quality program. Assist with development, conduct, review and analysis of HEDIS and QI program studies.

• Manage clinical aspects of the Credentialing Program.

• Recruit and manage qualified Physician Advisors, Behavioral Health Advisors and support staff to accomplish the CMO responsibilities.

Experience:

• 5 or more years of experience in direct patient care. Prefer experience in a nursing home working with long term residents.
• Experience in developing and implementing medical policy.
• Success in development and implementation of quality improvement initiatives.
• Participation in a utilization management committee.

Skills:

• Able to function well in a small highly accountable organization which has delegated entities responsible for core operational functions. Ability to work well and communicate with all levels of the organization.

• Leadership skills and the ability to perform tasks and assignments with minimal supervision. Demonstrated negotiation skills.

• Able to effectively represent the ACV and Simpra with external constituents and to communicate effectively with families, members and providers. Ability to influence internal and external constituents.

• Basic ability to use business applications including Word, Excel, Powerpoint, SharePoint and Outlook. Self-sufficient in office environment for scheduling.

Education:

Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) degree from an accredited school of medicine recognized by national medical regulatory bodies in the United States.

Licenses and Certifications:

• Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.).
• Unrestricted and current license to practice medicine in the State of Alabama (or the ability to obtain one).
• Board Certification

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