SVP Health Services & CMO

The Senior Vice President Health Services, and Chief Medical Officer is accountable for the development, implementation and maintenance of a market leading Health Services strategy for Commercial and Medicare Advantage products of Independence Blue Cross, AmeriHealth and AmeriHealth Administrators (Independence). The role is accountable for provider contracting including value-based contracts where applicable, development of medical, pharmacy and claims payment policy, and implementation of utilization management, case and condition management, population health, quality management programs and supporting health value optimization.

The strategy, programs, products and services are aligned with and support achievement of the corporate mission, vision, values and corporate strategy with special emphasis on improving health outcomes, member experience of healthcare, provider experience, affordability, and equity.

The position is also accountable for relationships with providers, vendors, regulators, legislators, brokers and consultants, and group customers on clinical and quality matters. The position assumes a leadership role to promote Independence and its mission vision, values, and contributions to improving the quality and affordability of healthcare locally, regionally and nationally. In this role the position participates on boards, committees and workgroups to drive local, regional and national policy on key healthcare related matters impacting benefit design, care delivery, reimbursement models, enabling technology, and consultative support services.

Duties and Responsibilities:

•  Responsible for contributing to development, maintenance and communication of the corporate mission, vision, and values, and the corporate strategy both internally and externally.

• Accountable for development, implementation and maintenance of the Health Services strategic imperatives that align with and support achievement of the corporate strategy.

• Accountable to negotiate, execute and monitor performance of provider and vendor contracts, including value-based contracts where applicable, in collaboration with Actuarial, Underwriting and Sales to achieve strategic imperatives related to value, affordability and total cost of care.

• Accountable for development, implementation and maintenance of market leading utilization management, case and condition management, population health, clinical care transformation, quality management and provider engagement programs that are compliant with applicable federal and State statutes and regulations and Accreditation requirements.

• Accountable for development, implementation and maintenance of medical, pharmacy and claims payment policies and associated processes and procedures, including engagement of appropriate experts as required from time to time.

• Accountable for supporting the health value optimization program and working across all involved divisions to monitor medical cost and utilization trends and identify medical cost improvement opportunities and to take the necessary actions to implement new programs and interventions to address these in support of achieving strategic goals. 

• Accountable to ensure ongoing analysis of unit cost, utilization, medical cost and health outcomes data by market segment, and to support cross-functional development and implementation of interventions and programs, internal or outsourced, that optimize utilization, cost of services, access to and coordination of care delivery, overall health outcomes, and performance on Stars, to achieve strategic goals.

• Develops constructive and collaborative working relationships with colleagues, providers, brokers, group customers, legislators, and regulators.

• Accountable to manage the divisional administrative budget to ensure Independence achieves its annual and strategic operating plan.

• Accountable to oversee the recruitment, development, training and retention of high potential human capital, and maintenance of a healthy work environment to maximize the operating performance of Independence.

• Accountable to cascade goals that align with the corporate and divisional strategy and drive optimal performance through the division annually.

• Accountable for annual performance evaluations of direct reports and assurance that same occurs through Health Services division.

Qualifications:

• Minimum of college and medical school/osteopathic school.

• Specialty Training and Board Certification:  Completion of a residency in an American Board of Medical Specialties (ABMS) approved specialty is preferred. Current Board Certification in an ABMS specialty is a requirement if it possible under the regulations of the individual certifying board as some specialty boards require active clinical practice as a pre-requisite for ongoing re-certification.

•  Must possess current, active, applicable state license to practice.  This license must not be subject to probation, proctoring requirements or other disciplinary action, to practice his/her specialty in each state where the practitioner is licensed, and additional certifications where required, to practice his/her profession and specialty.

• In good standing with Medicare, Medicaid and Federal DEA programs.

• Minimum of five years of management experience with responsibility for oversight of health services in a leadership role. Experience in HMO and PPO settings preferred.

• Managerial experience, including administrative budget accountability, of 5 years preferred.