Senior Vice President / Chief Clinical Officer, Utilization Management

Job title: Senior Vice President / Chief Clinical Officer, Utilization Management

Company: quantum-health


Job description: DescriptionLocation: 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 areFounded 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 roleThe 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 CMOWhat 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.—#LI-KT1#LI-RemoteWhat’s in it for you

• Compensation: Competitive base and incentive compensation
• Coverage: Health, vision and dental featuring our best-in-class healthcare navigation services, along with life insurance, legal and identity protection, adoption assistance, EAP, Teladoc services and more.
• Retirement: 401(k) plan with up to 4% employer match and full vesting on day one.
• Balance: Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more.
• Development: Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid trainings and leadership development.
• Culture: Recognition as a Best Place to Work for 15+ years, dedication to diversity, philanthropy and sustainability, and people-first values that drive every decision.
• Environment: A modern workplace with a casual dress code, open floor plans, full-service dining, free snacks and drinks, complimentary 24/7 fitness center with group classes, outdoor walking paths, game room, notary and dry-cleaning services and more!

What you should know

• Internal Associates: Already a Healthcare Warrior? Apply internally through Jobvite.
• Process: Application > Phone Screen > Online Assessment(s) > Interview(s) > Offer > Background Check.
• Diversity, Equity and Inclusion: Quantum Health welcomes everyone. We value our diverse team and suppliers, we’re committed to empowering our ERGs, and we’re proud to be an

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• Tobacco-Free Campus: To further enable the health and wellbeing of our associates and community, Quantum Health maintains a tobacco-free environment. The use of all types of tobacco products is prohibited in all company facilities and on all company grounds.
• Compensation Ranges: Compensation details published by job boards are estimates and not verified by Quantum Health. Details surrounding compensation will be disclosed throughout the interview process. Compensation offered is based on the candidate’s unique combination of experience and qualifications related to the position.
• Sponsorship: Applicants must be legally authorized to work in the United States on a permanent and ongoing future basis without requiring sponsorship.
• Agencies: Quantum Health does not accept unsolicited resumes or outreach from third-parties. Absent a signed MSA and request/approval from Talent Acquisition to submit candidates for a specific requisition, we will not approve payment to any third party.

Reasonable Accommodation: Should you require reasonable accommodation(s) to participate in the application/interview/selection process, or in order to complete the essential duties of the position upon acceptance of a job offer, to submit a recruitment accommodation request.Recruiting Scams: Unfortunately, scams targeting job seekers are common. To protect our candidates, we want to remind you that authorized representatives of Quantum Health will only contact you from an email address ending in @quantum-health.com. Quantum Health will never ask for personally identifiable information such as Date of Birth (DOB), Social Security Number (SSN), banking/direct/tax details, etc. via email or any other non-secure system, nor will we instruct you to make any purchases related to your employment. If you believe you’ve encountered a recruiting scam, report it to the and .

Expected salary:

Location: USA

Job date: Fri, 03 Jan 2025 08:15:07 GMT

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