Chief Clinical Officer of Utilization Management

1 month ago


Remote, Oregon, United States quantum-health Full time

Compensation: $120,000 - $180,000 per year, based on experience.

About Us

We are a privately-owned, independent healthcare navigation organization founded in 1999 and headquartered in Central Ohio. Our mission is to make healthcare simpler and more effective for our millions of members. We believe that no one should have to navigate the cost and complexity of healthcare alone.

We're committed to building diverse and inclusive teams so if you're excited about this position, we encourage you to apply – even if your experience doesn't match every requirement.

The Role

The Chief Clinical Officer of Utilization Management is responsible for the overall clinical performance of the Quantum Health UM programs across the enterprise. This includes 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.

You will also be responsible for managing efforts to ensure compliance of program to URAC, state department of insurance and other accrediting/regulatory bodies.

This role requires people leadership of UM physician team, including education, training, growth and development of employees. You will be accountable for overall performance of physician employees, including direct supervision of physician leaders in the UM program.

Key responsibilities include:

  • Developing, implementing and interpreting 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.
  • Overseeing UM quality management, including the development of processes to monitor clinical outcomes focusing on potential fraud, waste and/or abuse.
  • Collaborating 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.
  • Maintaining strong relationship with clients' leadership concerning UM, clinical criteria and policy, and provider issues, supported by operations as needed.
Requirements

To succeed in this role, you will need:

  • A 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.
Benefits

We offer a competitive compensation package, which includes:

  • Competitive base salary ($120,000 - $180,000 per year)
  • Incentive compensation
  • Health, vision and dental featuring our best-in-class healthcare navigation services
  • Life insurance
  • Legal and identity protection
  • Adoption assistance
  • EAP
  • Teladoc services
  • 401(k) plan with up to 4% employer match and full vesting on day one
  • Paid Time Off (PTO)
  • 7 paid holidays
  • Parental leave
  • Volunteer days
  • Paid sabbaticals


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