Vice President Clinical Service - Utilization Management & Appeals

Vice President Clinical Service - Utilization Management & Appeals
Oregon, Washington, Idaho, Utah
Primary Job Purpose
The Vice President Clinical Services is a member of the Health Services Organization (HSO) leadership team focused on enabling members to achieve their best health by simplifying their care journey, improving quality, supporting providers in their delivery of care, and managing total cost. The VP of Clinical Services is accountable for clinical functions which may include care management, transition of care services, medical policy development and implementation, Utilization Management, facility stay reviews and appeals.
This role helps shape and drive strategy and execution in support of integrated business solutions aligned to the needs of each health plan line of business (e.g. Medicare, individual, ASO, etc.). The position oversees internal programs and external vendors and plays a key role in medical cost stewardship and ensuring clinical quality of services to members.
General Functions and Outcomes

• Provides leadership in developing, implementing, and communicating short and long-range plans, goals and objectives for the function.
• Aligns team goals with the organization's vision and strategy.
• Develops strategies and tactics to effectively manage healthcare costs and improve clinical quality across all product lines.
• Partners with leaders and stakeholders across the enterprise to prioritize activity and solutions in support of medical management strategies and operational plans.
• Develops, recommends, and implements clinical and operational policies and procedures.
• Develops and manages performance against business, financial, utilization, and operational metrics to ensure results are achieved across Clinical Services functions and various Lines of Business.
• Analyzes and uses information and data to guide the development and implementation of new or enhanced health care interventions that improve value to the member and payers.
• Ensures programs meet federal and state regulations, accreditation standards, quality metrics, client requirements and evolving models of care (e.g. accountable care organizations, patient centered homes).
• Determines appropriate staffing levels and resource needs, creates and manages department and/or project budgets, allocates resources and approves expenditures.
• Fosters an effective work environment and ensures employees receive appropriate communication, recognition, and professional development.
• Participates in organizational talent management and succession planning.
  

Minimum Requirements

• Expertise related to health insurance industry trends, evolving accountable care and payment models, case and Utilization Management programs and how to best partner with providers to achieve desired outcomes.
• Strong communication and facilitation skills with all levels of the organization, including the ability to resolve issues and build consensus among groups of diverse internal/external stakeholders.
• Strong leadership, negotiation and relationship building skills.
• Deep business acumen including understanding of market dynamics, financial/budget management, data analysis and decision making.
• Demonstrated competency related to creating and executing business strategies and driving results within a large, complex organization and/or with external partners.
• Proven ability to implement and execute successful business transformation and lead through change.
• Proven ability to develop a high performing team and manage and develop leaders.

The Vice President Clinical Services would have a bachelor's degree in business management, health administration or a related field, 10 years of management/leadership experience and five years of experience as a director for a health plan with responsibility for medical cost and quality management, with experience in delivering health care insurance programs or an equivalent combination of education and experience
FTEs Supervised
4-6 direct reports and oversees a staff > 200.
Work Environment
Duties are performed primarily in an office environment.
Travel to other TRG affiliate plans and to regional offices may be required.
The expected hiring range for a Vice President Clinical Service - Utilization Management & Appeals is $283,100-382,950 depending on skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The bonus target for this position is 30% . The current full salary range for this role is $266,000-433,000.
Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:

• medical, dental, and vision coverage for employees and their eligible family members
  
• annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
  
• paid time off varying by role and tenure in addition to 10 company holidays
  
• up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
  
• up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
  
• one-time furniture and equipment allowance for employees working from home
  
• up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.
  

We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site.