Remote Prior Authorization Analyst Jobs in Kentucky

Our Company

Abilis Health Plan

Overview

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. The CMO is responsible for the strategic direction and oversight of clinical programs including utilization management, clinical operations, quality, population health, and pharmacy operations to ensure safe, effective, and financially responsible care for members in long term care settings. 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.

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.
• Participate as a key member of the executive leadership team in strategic planning, product design, benefit strategy, and growth initiatives.
• Represent the health plan with regulators, external partners, and professional organizations as the senior clinical spokesperson.

Qualifications

• 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)
• Current board certification in an appropriate medical specialty.
• Ability to maintain all licenses, certifications, and professional memberships required by the organization and applicable regulatory bodies.
• In depth knowledge of Medicare Advantage, Special Needs Plans (I-SNP/IE-SNP), CMS regulations, and related clinical and compliance requirements.
• Strong understanding of utilization management, quality measurement (including Stars and HEDIS), care management models, and pharmacy management in a managed care environment.
• Proven leadership skills, including ability to lead and influence physicians and multidisciplinary teams, drive accountability, and manage change.
• Excellent analytical skills with the ability to interpret clinical, financial, and operational data and translate insights into actionable strategies.
• Strong communication and presentation skills, with the ability to explain complex clinical and regulatory concepts to clinical and nonclinical stakeholders, executives, boards, and external partners.
• Demonstrated ability to build collaborative relationships with providers, facilities, and community partners in a highly regulated, performance driven environment.
• Strategic, systems level thinker with the ability to balance clinical quality, member experience, regulatory requirements, and financial stewardship.
• High integrity, sound clinical judgment, and commitment to ethical decision making and member centered care.

About our Line of BusinessAbilis Health Plan, an affiliate of BrightSpring Health Services, is a Medicare Advantage Plan covering all the benefits of Original Medicare (Parts A and B) with prescription drug coverage (Part D). The Abilis Health Plan is a unique plan allowing members to enroll year-round. The plan focuses on members who meet residential requirements in participating nursing facilities. An interdisciplinary team of clinicians and innovative services allow us to meet each member's clinical needs and provide preventive, coordinated, and quality healthcare. With a dedicated nurse practitioner leading a personalized care plan, we strive to improve the health of the communities in which we serve. For more information, please visit www.abilishealth.com. Follow us on LinkedIn.Employment Type: FULL_TIME