AVP, Clinical Performance

NeueHealth

1d•Remote

About The Position

NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid. NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all. SCOPE OF ROLE The AVP of Clinical Performance oversees the strategy, operations, and performance of Delegated Utilization Management (UM) and Care Management (CM) programs that ensure healthcare services are medically necessary, cost-effective, and aligned with payer and regulatory requirements. This role will be directly responsible for the management of clinical capabilities related to delegated utilization management and delegated care management across multiple health plan clients in the California Medi-Cal, Medicaid delegated services markets. This is a work from home position based in California or the Pacific Time Zone.

Requirements

Bachelor’s Degree in business, healthcare administration, nursing, or a related field is required; MBA/MHA and/or clinical degree is preferred.
Minimum of ten (10) years of MSO operations experience, with at least five (5) years in a national/regional management role required.
Experience in change management and process improvement required.
Ability to operate effectively in a matrixed environment
Strong clinical leadership, communication, and relationship-building skills
Results-driven, with the ability to translate strategy into measurable outcomes
Proven success leading organizational change and performance improvement
Strong collaboration and cross-functional alignment capabilities
Deep clinical acumen with expertise in utilization review and management
Strong analytical and presentation skills
Experience developing and leading governance models for care and utilization management

Nice To Haves

Registered Nurse license is preferred.

Responsibilities

Drive quality, efficiency, and consistency using internal and external benchmarks
Lead and develop UM/CM Directors; set clear direction, accountability, and performance expectations
Ensure standardized operations and workflows
Collaborate with operational and medical director leadership of affiliate partners
Partner with finance and clinical leaders to align staffing, skill mix, and resources
Foster a culture of high performance, continuous improvement, and regulatory excellence
Oversee daily UM and CM operations to ensure effective care coordination and utilization review
Lead UM programs including prior authorization, concurrent, retrospective review, and medical necessity determinations
Ensure compliance with federal, state, health plan and NCQA requirements
Manage authorization turnaround times to exceed payer standards
Oversee denial processes, notifications, and timeliness requirements
Identify opportunities to reduce unnecessary utilization while maintaining quality
Support value-based contract performance through effective utilization controls
Partner with CMO and Medical Directors to meet regulatory and compliance standards
Support internal and health plan audits and ensure proper clinical review hierarchy
Oversee inpatient and complex care management programs
Ensure compliance with federal, state, and NCQA care management standards
Establish standardized workflows, care plans, and documentation practices
Integrate care management into physician workflows and primary care teams
Participate in and support internal and health plan audits