Chief Medical Officer - Health Plan

Location Address

9521 San Mateo NE

Albuquerque, NM 87113-2237

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.

Work Arrangement

• 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.

Job Description

Senior Clinical Leadership

• 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. Utilization Management Decision Responsibility
• 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. Medical Policy and Clinical Criteria
• 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. Clinical Oversight of Care Management
• 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 clinically sound and focused on the right populations. Medical Cost and Utilization Leadership
• Partner with the Healthcare Value Leader, Finance, Actuarial, Analytics, and Network to review medical cost and utilization trends.
• Provide physician leadership on initiatives related to inpatient utilization, ED utilization, post-acute care, specialty variation, site-of-care optimization, pharmacy trends, and avoidable admissions.
• Support development of clinical interventions that reduce unnecessary utilization while preserving access and quality.
• External CMO benchmarking includes accountability for leading medical cost and utilization analysis and correcting identified or anticipated utilization issues while assuring members receive needed care. Provider and Physician Engagement
• Serve as the health plan’s senior clinical representative to physicians, provider groups, and delivery system leaders.
• Lead physician-to-physician conversations on medical necessity, utilization variation, care standards, documentation, quality improvement, and value-based performance.
• Support provider education related to clinical criteria, medical policies, UM expectations, appeals, and evidence-based practice. Quality, Risk Adjustment, and Behavioral Health Partnership
• Partner with the SVP Quality, Behavioral Health, and Risk Adjustment to ensure clinical strategy aligns with quality, risk adjustment, behavioral health integration, equity, accreditation, and regulatory requirements.
• Provide clinical support for HEDIS, Stars or equivalent quality programs, care gap closure, chronic disease management, and clinical quality initiatives.
• Avoid duplicating the SVP Quality/BH/RA role by focusing on clinical authority, medical necessity, medical policy, and physician engagement.

Additional Job Description

Other Information

(Education, Certifications and Minimum Job Requirements) Required

• MD or DO from an accredited medical school
• Active, unrestricted medical license – New Mexico
• Board certification
• 10 or more years of relevant clinical and health care leadership experience
• Managed care, health plan, medical director, UM, quality, population health, or medical management leadership experience
• Experience with medical necessity review, appeals, peer review, clinical criteria, medical policy, and regulatory/accreditation requirements
• Strong physician leadership, executive communication, business acumen, and influence skills

Preferred

• Prior experience as a health plan CMO, deputy CMO, associate CMO, or senior medical director
• Experience in Medicare Advantage, Medicaid, commercial health plan, provider-sponsored health plan, or integrated delivery system
• Experience with NCQA, URAC, CMS, state regulatory requirements, HEDIS/Stars, value-based care, behavioral health integration, and risk adjustment
• Advanced degree such as MBA, MHA, MPH, MMM, or equivalent
• CPHQ, CPE, or equivalent physician leadership/quality credential

Benefits

Benefits are effective day-one (for .45 FTE and above) and include

• Competitive salaries
• Full medical, dental and vision insurance
• Flexible spending accounts (FSAs)
• Free wellness programs
• Paid time off (PTO)
• Retirement plans, including matching employer contributions
• Continuing education and career development opportunities
• Life insurance and short/long term disability programs

About Us

Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.

Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.