Vice President, Clinical Services & Operations

Medical Mutual•Cleveland, OH

1d•Onsite

About The Position

The Vice President of Clinical Services & Operations provides strategic leadership for the company’s Clinical Delivery teams, including Prior Authorization, Acute and Post-Acute Care, Case Management, and Medicare Clinical Services. Reporting to the Chief Medical Officer (CMO), this leader shapes and executes high-impact clinical initiatives and develops executive communications that advance organizational priorities.

Requirements

Bachelor’s Degree in nursing or similar clinical area of study required.
Registered Nurse with current State of Ohio unrestricted license required.
10 years progressive health care plan management experience in multiple areas of clinical care management (utilization, case, or disease) or quality, and which includes government programs (Medicare, Medicaid)
Comprehensive knowledge of the health care continuum including population health, chronic condition management, provider reimbursement, and the ability to apply strategically.
Comprehensive knowledge of applicable state, federal, and third-party regulations and the ability to apply advanced concepts to business operations.
Strong knowledge of Medicare Advantage and other government program requirements.
Knowledge of multiple commercial lines of business including Commercial Fully Insured, Self-Funded and Exchange products.
Knowledge of profit and loss.
Strong verbal and written communication skills including the ability to communicate ideas to leadership.
Proficiency with Microsoft Office, database reporting, and clinical systems.

Nice To Haves

Master’s degree in Business or Health Care Administration or related field preferred.

Responsibilities

Directs cross-functional teams through planning, development, evaluation, and implementation of Division initiatives across the organization and in collaboration with care delivery network and other business partners to achieve value-based outcomes including Medical Management, Clinical Operations, Provider Engagement, etc.
Partners with VPs and business owners to advance clinical innovation and optimize strategies through process improvement, best practices, and performance analysis to improve utilization, cost, quality, and member satisfaction.
Achieves medical management operational and financial objectives for all at risk patient populations (Medicare, Medicare Advantage, ACO and health plans).
Promotes cost-effective practice patterns through interventions with healthcare providers.
Serves as a strategic advisor to the CMO, managing clinical inquiries, communications, and key meetings while prioritizing critical issues to support informed and efficient decision-making.
Coordinates Division budget and prepares for CMO review and approval.
Oversees member, provider, and clinical communication materials and documents for clinical content and program accuracy for all products related to utilization and case management programs and services.
Oversees post-acute management of third-party service providers to reduce variations in care and episode costs.
Represents Clinical Operations as a subject matter expert in customer and broker presentations.
Performs other duties as assigned.

Benefits

Laptop, monitors, keyboard, mouse and headset provided.
Access to on-site fitness centers or gym membership reimbursement.
On-site cafeteria.
Discounts at many places in and around town.
Opportunity to earn cash rewards for shopping with customers.
Business casual attire, including jeans.
Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Medical, dental, vision, life and disability insurance.
Access to an Employee Assistance Program.
Company holidays.
Up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
Parental leave for eligible employees who become parents through maternity, paternity or adoption.
Career development programs and classes.
Mentoring and coaching.
Tuition reimbursement up to $5,250 per year.
Diverse, inclusive and welcoming culture with Business Resource Groups.