Location: This position may work remotely anywhere in the United States of America with significant business travel to and from prospect/client sites and/or the Quantum Health home office in Dublin, OH.
Who we are
Founded in 1999 and headquartered in Central Ohio, we’re a privately-owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare simpler and more effective for our millions of members. Our big-hearted, tech-savvy team fights to ensure that our members get the care they need, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare Warriors®.
We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement.
About the role
The Vice President / Chief Clinical Officer of Utilization Management (UM) is responsible for the overall clinical performance of the Quantum Health UM programs across the enterprise, including clinical policy, quality management, program development and innovation, review of UM cases against clinical criteria and provider issues, ensuring clinical integrity of the UM program to improve clinical outcomes for members and manage cost and utilization trends for clients. The VP, CCO of UM will also manage efforts to ensure compliance of program to URAC, state department of insurance and other accrediting/regulatory bodies.
What you’ll do (Essential Responsibilities)
· People leadership of UM physician team, including education, training, growth and development of employees. Accountable for overall performance of physician employees, including direct supervision of physician leaders in the UM program
· Be responsible for overall medical policies of the company to ensure the appropriate and most cost effective medical care is received.
· Collaborate with Operations leadership to ensure optimal clinical review quality, timing and operational efficiency of all UM programs.
· Develop, implement and interpret medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments.
· Responsible for development of clinical policy, clinical review decisions, appeals, audits, and other clinical functions, supported by operations, and implement corrective actions when required.
· Oversee UM quality management, including the development of processes to monitor clinical outcomes focusing on potential fraud, waste and/or abuse.
· Collaborate closely with Legal and Compliance teams to ensure optimal performance at all audits conducted by URAC, state departments of insurance, or/or other outside regulatory bodies.
· Evaluation of utilization trends and patterns, quality standards, program performance, and client feedback as necessary to recommend solutions for improvement where needed.
· Maintain strong relationship with clients’ leadership concerning UM, clinical criteria and policy, and provider issues, supported by operations as needed.
· Provide executive clinical subject matter expertise (SME) for all UM program at Quantum Health
· Serve as executive clinical SME for marketing, sales and client executive group as assigned by CMO.
· Other related duties as assigned by CMO
What you’ll bring (Qualifications)
· MD/DO with unrestricted license. Board Certification by the American Board of Medical Specialties.
· Minimum of 10 years in the health care industry, including 5 years’ experience in clinical practice
· Minimum of 5 years’ experience in a senior health care management position managing people and large scale projects and initiatives.
· Minimum 5 years experience as a Utilization management medical director. Deep knowledge of health plan utilization management functions, URAC standards, and applicable federal and state department of labor laws.
· Ability to work collaboratively and consultatively with others. Ability to influence others through data, negotiation, and presentation
· Unrelenting curiosity and innate desire to explore and understand what makes Quantum Health and its business work, coupled with a pragmatic approach to problem solving
· Ability to arrive at practical, actionable solutions that are executable and drive a commitment to the company’s value proposition and culture
· Computer expertise with Microsoft office suite, Interqual, and other UM focused software programs
· Strong bias for action and teamwork
· Ethically sound decision making
· Travel to clients as needed 20% of time
· Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
· A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health’s policies, values and ethics, and to protecting the sensitive data entrusted to us.
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