Chief Medical Officer

7w1 month ago

BrightSpring Health Services

Louisville, US · Full-time · $280,000 – $380,000

About this role

The Chief Medical Officer (CMO) provides executive clinical leadership for Abilis Health's Institutional Special Needs Plan (I-SNP) and Institutional-Equivalent Special Needs Plan (IE-SNP) Medicare Advantage products. This role is responsible for the strategic direction and oversight of clinical programs including utilization management, clinical operations, quality, population health, and pharmacy operations.

Day-to-day responsibilities include overseeing utilization management processes such as prior authorization criteria, medical necessity determinations, concurrent review, and appeals to ensure evidence-based and compliant decision making. The CMO also leads clinical operations including care management, transitional care, and interdisciplinary team processes to improve outcomes and reduce preventable utilization.

The CMO serves as the senior physician executive, partnering with the CEO and leadership team to drive clinical performance, regulatory compliance, and an integrated model of care for high-acuity, medically complex populations in long term care settings. This role collaborates with network physicians, facility medical directors, advanced practice clinicians, and facility leadership to support consistent, high quality care delivery.

As a key member of the executive leadership team, the CMO participates in strategic planning, product design, benefit strategy, and growth initiatives. This position also represents the health plan with regulators, external partners, and professional organizations as the senior clinical spokesperson.

Requirements

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required.
Completion of an accredited residency program and board certification in an appropriate specialty.
Minimum of 7–10 years of clinical practice experience, with at least 3–5 years in health plan, managed care, or population health leadership roles.
Demonstrated experience leading utilization management, quality improvement, and care management functions in a payer, integrated delivery system, or large group practice.
Experience with Medicare Advantage, Special Needs Plans, or comparable government programs strongly preferred.
Prior leadership experience working with long term care, nursing facilities, assisted living, or other institutional/complex geriatric populations preferred.
Active, unrestricted medical license in at least one state in which the plan operates; eligibility for additional state licensure as needed. (KY, TN)
In depth knowledge of Medicare Advantage, Special Needs Plans (I-SNP/IE-SNP), CMS regulations, and related clinical and compliance requirements.

Responsibilities

Provide overall clinical leadership for the plans products, including development and execution of the clinical strategy aligned with organizational goals.
Oversee utilization management, including prior authorization criteria, medical necessity determinations, concurrent review, and appeals, ensuring evidence based and compliant decision making.
Lead clinical operations, including care management, transitional care, and interdisciplinary team processes to improve outcomes and reduce preventable utilization.
Oversight and collaboration with the VP of Quality to develop the Stars strategy, quality improvement initiatives, clinical guidelines, performance monitoring, Model of Care and corrective action plans.
Provide clinical oversight of pharmacy strategy, including formulary design input, medication management programs, appropriate use initiatives, and coordination with Part D partners.
Review and interpret clinical, utilization, and quality data to identify trends, risk areas, and opportunities for improvement; implement interventions and track impact.
Collaborate with network physicians, facility medical directors, advanced practice clinicians, and facility leadership to support consistent, high quality care delivery.
Partner with compliance and regulatory teams to ensure adherence to CMS regulations, audit readiness, and timely response to regulatory changes.

Benefits

Executive-level clinical leadership role with strategic influence across the organization.
Opportunity to shape clinical programs for high-acuity, medically complex populations in long term care settings.
Collaboration with a multidisciplinary executive team including the CEO, VP of Quality, and pharmacy leadership.
Representation of the health plan with regulators, external partners, and professional organizations.