Chief Medical Officer, Health Plans

The Chief Medical Officer (CMO) serves as the organization's senior clinical executive, providing strategic medical leadership and physician oversight across the enterprise. The CMO is responsible for advancing clinical excellence, quality, and evidence-based care while ensuring the organization's medical management programs align with regulatory requirements, value-based care principles, and organizational goals.

Working closely with executive leadership, the CMO provides clinical guidance and oversight for Care Management, Utilization Management, and Grievance & Appeals, ensuring these functions operate with clinical integrity, regulatory compliance, and a member-centered approach. The CMO partners across the organization to improve health outcomes, advance health equity, strengthen care coordination, and responsibly manage healthcare resources for diverse populations.

Executive Clinical Leadership

• Serve as the organization's senior physician executive and trusted advisor on clinical strategy, medical policy, quality, and population health.
• Provide clinical leadership and guidance to executive and departmental leaders responsible for Care Management, Utilization Management, and Grievance & Appeals.
• Develop and advance clinical strategies that support organizational priorities, improve member outcomes, and promote high-value care.
• Foster a culture of clinical excellence, innovation, accountability, and continuous quality improvement.

Medical Management & Clinical Quality

• Provide physician oversight for medical management activities to ensure evidence-based, equitable, and cost-effective care.
• Support the development, implementation, and evaluation of medical policies, clinical guidelines, utilization management criteria, and care management programs.
• Collaborate with Quality, Compliance, and Operations leaders to monitor clinical performance, identify opportunities for improvement, and implement corrective actions.
• Review clinical trends, utilization patterns, appeals outcomes, and quality metrics to guide strategic decision-making.
• Promote integration of medical, behavioral health, pharmacy, and social determinants of health into care delivery models.

Regulatory & Compliance Leadership

• Ensure clinical operations comply with CMS, New York State Department of Health (DOH), NCQA, and other applicable regulatory and accreditation standards.
• Provide clinical leadership during regulatory audits, accreditation reviews, and external examinations.
• Partner with Compliance and Quality teams to proactively identify clinical risks and ensure regulatory readiness.
• Represent the organization's clinical perspective with regulators, accrediting organizations, providers, and other external stakeholders.

Strategic Collaboration

• Partner with leaders across Quality, Pharmacy, Risk Adjustment, Provider Network Management, Member Services, and Operations to align clinical strategy with organizational objectives.
• Support initiatives focused on value-based care, population health, health equity, and integrated care delivery.
• Collaborate with provider partners to strengthen clinical performance, quality outcomes, and member experience.
• Provide physician leadership for enterprise initiatives that improve care coordination and healthcare affordability.

Physician Leadership

• Mentor and support physician leaders and clinical subject matter experts across the organization.
• Foster collaboration among multidisciplinary teams to achieve organizational goals.
• Promote evidence-based decision-making and professional development throughout the clinical organization.

Education

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Board certification in an ABMS or AOA-recognized clinical specialty.
• Active, unrestricted license to practice medicine.
• New York State medical license or eligibility to obtain licensure preferred.

Experience

• Minimum of 15 years of progressive physician leadership experience within managed care, health plans, integrated delivery systems, or value-based healthcare organizations.
• Demonstrated expertise in clinical quality improvement, medical policy development, utilization management, care management, and regulatory compliance.
• Extensive knowledge of Medicare, Medicaid, Managed Long-Term Care (MLTC), Dual Eligible Special Needs Plans (D-SNP), and other government-sponsored healthcare programs.
• Experience leading value-based care, population health, and clinical transformation initiatives.
• Proven ability to influence executive leaders and build collaborative relationships across complex organizations.
• Experience representing organizations with regulatory agencies, accrediting bodies, providers, and community stakeholders.

Preferred Qualifications

• Additional training or certification in Managed Care, Population Health, Geriatrics, Public Health, or Healthcare Administration.
• Experience serving as a Chief Medical Officer, Deputy Chief Medical Officer, or Medical Director within a Medicare, Medicaid, or integrated care organization.
• Experience with NCQA accreditation, CMS Star Ratings, HEDIS, and quality performance programs.