Senior Vice President of Clinical Excellence
4 days ago
The Senior Vice President of Clinical Excellence is responsible for leading the overall clinical performance of Quantum Health's Utilization Management (UM) programs. 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.
Key Responsibilities- People leadership of the 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.
- 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.
- Closely collaborate 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.
- Evaluate utilization trends and patterns, quality standards, program performance, and client feedback as necessary to recommend solutions for improvement where needed.
- Maintain strong relationships with clients' leadership concerning UM, clinical criteria and policy, and provider issues, supported by operations as needed.
- 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.
- 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.
$150,000 - $200,000 per year, depending on experience.
BenefitsQuantum Health offers a comprehensive benefits package, including:
- 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.
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