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POSITION SUMMARY:

The Office of Clinical Affairs (OCA) is responsible for establishing and monitoring a pro-active system of clinical integrity and accountability, which assures the delivery and purchase of clinically effective, high quality, equitable and cost efficient healthcare for members enrolled in MassHealth. MassHealth is the Massachusetts Medicaid program administered by the Office of Medicaid within the Executive Office of Health and Human Services (EOHHS).

The Chief Medical Officer (CMO) serves as the Medical Director for MassHealth and Executive Leader of OCA, exercising medical and clinical oversight of all the healthcare services MassHealth provides. This position has accountability for medical policy/medical review, appeals, quality, clinical development of medical cost reduction initiatives and serving as the spokesperson for MassHealth on clinical aspects. The CMO will work with MassHealth to execute the clinical transformation strategy. This individual ensures the development and implementation of clinical policies, standards, and practices consistent with sound medical practice that affects the MassHealth members as well as the provider and advocacy communities. The MassHealth CMO oversees all clinical aspects of the operation and management of the OCA. In this role, she/he is responsible for building consensus with the Associate Medical Directors, the Medical Director Working Group and the Drug Utilization Review Board. She/he serves as the chief medical advisor to the Medicaid Director, and through the staff of OCA as the Medical Director for MassHealth’s Primary Care Clinician Plan. The MassHealth CMO, directly and through the staff of OCA, serves as a clinical resource to the entire MassHealth program and its staff.   The MassHealth CMO will also serve as the Director and Executive Leader of OCA. All final medical decision-making for MassHealth ultimately resides under the purview of the CMO, in consultation with the Medicaid Director in the Office of Medicaid.

The MassHealth CMO also serves in a leadership role in Commonwealth Medicine/University of Massachusetts Medical School (CWM/UMMS). She/he serves as the primary clinical liaison between the Office of Medicaid and CWM -, and as a member of the leadership team of CWM. Based on interest and availability, the MassHealth CMO may participate in the academic and research activities of UMMS.

ESSENTIAL FUNCTIONS:

Clinical Leadership

• Leadership of clinical policy and program development and of the initiation of clinical strategies to contain costs and improve quality, including through the elimination of racial and ethnic disparities.
• Serve as the CMO of MassHealth, and Director and Executive Leader of OCA.

Consultation to:

• The Medicaid Director; Medicaid Management Team; MassHealth benefit plan managers, Medicaid program managers and, as requested by the Medicaid Director or CWM -Managing Director, Clinical Delivery Solutions (MDCDS), other EOHHS state clusters/agencies; on policy development, policy issues, organizational goals, vendor management, and any other activities necessary and useful in improving access and quality of healthcare to MassHealth members, and on clinical policy issues of importance to the Office of Medicaid.
• Management of the development of clinical standards, best practice guidelines, algorithms, and clinical policy designed to improve the healthcare delivered to MassHealth members in any setting by any provider or vendor within the Commonwealth or outside of the Commonwealth.
• Management of the development and approval of clinical contractual outcomes included in all Managed Care Organizations (MCO) and provider (hospital, nursing facility, physician, laboratory, etc) contracts or agreements.
• Clinical oversight of the Office of Medicaid’s pharmacy and dental programs.
• Clinical oversight of the Office of Medicaid’s Prior Authorization and Utilization Management programs.
• Liaison activities with external groups and associations on clinical policy issues important to the Massachusetts Medicaid program.
• Oversight and monitoring of all provider compliance controls mandated by federal, state and Medicaid
• Assure the quality of clinical services purchased by Medicaid.
• Clinical oversight of the standards and processes for credentialing of MassHealth providers.

Quality Management

• Management of clinical aspects of the development and implementation of an integrated monitoring and evaluation system within the Office of Medicaid and among its contractors.
• Technical assistance, including consultation to the Office of Medicaid and as directed by the Medicaid Director or CWM MDCDS, EOHHS cluster groups on training for clinical, quality related and culturally sensitive issues.
• Dissemination of the clinically-related principles of Quality Management and clinical evaluation to the Office of Medicaid and EOHHS cluster groups as needed.

Evaluation and Data Management

• Oversee the assessment and reports on new and emerging drugs, technologies, medical, surgical and experimental procedures and develop evidence-based clinical policies.
• Work with various internal and external stakeholders to develop the ability to integrate multiple databases in order to monitor the quality, the clinical effectiveness, and cost effectiveness of the services and products provided to MassHealth members.
• Work with other parts of CWM /UMMS to carry out guideline development, education of providers and evaluation of programs and systems.
• Keeps abreast of and ensures compliance with State and federal and healthcare regulations.
• Directs adherence to legal decrees, agreements and court mandates with respect to medical and dental care.

Administrative Leadership

• Assure optimal UMMS contractual relationships.Oversees the professional development of senior staff and manages performance to ensure the retention and engagement of a highly effective and high performing team.
• Oversee monitoring of operational, quality, and financial outcomes, metrics and benchmarks to ensure sustained success and high levels of quality.
• Ensure the successful achievement of business and fiscal objectives.

REQUIRED QUALIFICATIONS:

• Medical Doctor with Board Certification, a current valid Massachusetts medical license.
• Candidates with current licensure in another state and the ability to obtain Massachusetts licensure within 6 months will be considered
• 7 years clinical experience preferably serving diverse and/or low income populations.
• 5 years management experience within a large organization providing healthcare related services.
• Knowledge of and experience with quality management theory and practice.
• Knowledge of and experience with healthcare systems’ development and change, including the organization and systems involved in managed care.
• Strong written and verbal communication skills, as well as strong interpersonal skills are essential.
• Advanced training or graduate degree in management, public policy, public health or business administration desirable.
• Experience in public policy and/or public administration or healthcare management. Experience with Medicaid or other public programs or private payers particularly desirable.
• Experience in a management role in a managed care organization or health plan desirable.