CareCentrix

General

• Conduct medical necessity reviews for cases that may not meet established criteria and issue adverse determinations when appropriate
• Evaluate requests across post-acute care services in alignment with clinical and regulatory standards
• Meet or exceed Service Level Agreements (SLA) and performance guarantees required by health plan clients
• Apply sound clinical judgment and maintain integrity in all determinations and interactions
• Collaborate effectively with internal and external stakeholders, including providers and physicians
• Perform other duties as assigned

Physician Reviewer – Part Time

Vice President

• Partner with the President and senior leadership team to define, prioritize, and execute company-wide strategic initiatives.
• Translate strategic objectives into actionable plans, milestones, deliverables, and governance routines, while owning and maintaining accountability for successful execution and delivery.
• Drive cross-functional alignment across departments to ensure priorities are clearly understood, coordinated, and executed effectively.
• Identify risks, dependencies, barriers, and opportunities that may impact the delivery of strategic priorities and develop mitigation plans as needed.
• Lead and support high-impact initiatives that span multiple business functions and require executive visibility and engagement.
• Lead the development and ongoing management of corporate and operational dashboards, delivering accurate, actionable insights to leadership.
• Oversee consistent reporting and performance analysis of key indicators across contracting, provider access, operational performance, service metrics, and other priority business areas.
• Gather, analyze, and communicate key performance metrics that inform decision-making and business outcomes.
• Deliver executive-facing analytics, business reviews, and performance narratives that highlight trends, risks, opportunities, and recommended actions.
• Leverage data and insights to proactively identify and recommend opportunities to improve organizational performance and operational effectiveness.
• Support annual budgeting and quarterly forecasting processes through performance analytics, business insights, and executive-level reporting.
• Partner with leaders to conduct ROI analyses that support prioritization of cost savings, efficiency initiatives, and operational improvements.
• Provide visibility into costs, ROI, resource allocation, and progress against budget and strategic objectives.
• Identify opportunities to improve technology, reporting capabilities, and business processes that enhance operational efficiency and organizational effectiveness.
• Champion a culture of continuous improvement by identifying inefficiencies and implementing practical solutions that streamline operations and improve quality outcomes.
• Manage executive priorities, leadership meeting cadences, follow-up actions, and preparation of materials for key leadership discussions.
• Oversee enterprise-wide communication and meeting support for the President, including town halls, senior leadership meetings, and organizational announcements.
• Ensure clear and consistent communication of priorities, decisions, progress, and expectations across leadership teams and the broader organization.
• Build strong, trusted partnerships across the organization to foster collaboration, alignment, and effective execution.
• Provide strategic and operational support on additional priorities and initiatives as requested by the President.
• Lead, coach, and develop a team responsible for enterprise planning, performance reporting, analytics, corporate communications, and executive support for the President and senior leadership team.
• Establish clear expectations, priorities, and operating rhythms that drive accountability and high-quality execution.
• Foster a collaborative, accountable, and service-oriented culture focused on business impact, continuous improvement, and organizational success.

AVP – Planning and Performance

• Lead the development and execution of enterprise-wide provider network and contacting strategies to ensure network adequacy, competitive positioning, and alignment with business growth objectives
• Define and drive multi-year provider contracting roadmaps, including rate strategy, value-based care models, and risk-sharing arrangements
• Oversee network design, expansion, and optimization across markets, ensuring alignment to cost-of-care targets, access standards, and product strategy
• Utilize market intelligence, competitive insights, and performance analytics to inform network composition and contracting priorities
• Ensure network configurations balance cost efficiency, quality outcomes, and provider access including optimization of high performing and preferred provider tiers
• Direct end-to-end provider network development, including contracting strategy, negotiation execution, reimbursement methodologies, and ongoing performance management
• Establish and implement innovative contracting models (e.g. value-based care, bundled payments, shared savings, capitation where appropriate) to drive cost, quality, and experience outcomes
• Lead complex provider negotiations with health systems, specialty providers, and ancillary partners, ensuring alignment with financial targets and strategic priorities
• Identify and executive opportunities to strengthen network performance through contract optimization, utilization management alignment, and provider incentives
• Oversee network capacity planning, coverage adequacy, and provider mix optimization to meet demand and growth projections
• Drive enhancements to provider-facing tools, systems, and processes to improve operational efficiency and experience
• Ensure all network initiatives and contracting programs delivery against defined KPIs, including affordability, unit cost reductions, ROI and performance guarantees
• Partner with Product, Clinical, and Market leaders to align network capabilities with product design and clinical program requirements
• Ensure provider contracts and reimbursement structures support new product features, care models and clinical program requirements
• Enable scalable network and contracting solutions to support new market entry, product launches, and client-specific configurations
• Lead the development of network-related program capabilities and positioning to support client growth and retention
• Partner closely Sales, Underwriting, Medical Economics, and Actuarial teams to align network contracting strategy with pricing, underwriting assumptions and growth targets
• Support pre-sale and post-sale activities through network strategy articulation, provider disruption analysis, and competitive positioning
• Ensure timely adaptation of network models in response to evolving healthcare landscape and client needs
• Serve as a key liaison between Network Management, Product / Network Analytics, Medical Economics, Provider Experience, Clinical Operations, Compliance, Revenue Cycle Management (RCM), Implementations and Operations teams
• Align stakeholders around contracting strategies, financial targets, and execution plans, ensuring seamless operationalization
• Provide strategic input into enterprise priorities, including cost-of-care management, provider partnerships, and long-term growth strategy
• Represent CareCentrix in executive-level negotiations with provider organizations, health systems and strategic partners
• Build and maintain strong, collaborative provider relationships that enable favorable contracting outcomes and long-term partnership value

AVP – Provider Strategy, Contracting

Medical Director

• Provides clinical oversight and utilization management for Home Health, Durable Medical Equipment (DME), Home Infusion Therapy, Sleep Medicine, and related services.
• Conducts medical necessity reviews using industry-standard clinical criteria and evidence-based guidelines to support coverage determinations and quality care outcomes.
• Conducts efficient medical necessity reviews and peer to peer consultations in adherence with regulatory and compliance turnaround times on cases that may not meet clinical criteria.
• Issues adverse determinations as needed.
• Provides guidance to licensed and non-licensed associates on clinical issues and case reviews related to authorization requests and clinical guidelines criteria.
• Completes peer to peer discussions when medical necessity criteria are not met.
• Participates in CareCentrix Care Coordination, Utilization Management, Quality Improvement and clinical education activities, as requested.
• Utilizes clinical integrity in all determinations and interactions with internal and external partners.
• Collaborates with Health Plan clinical leadership as requested.
• Achieves Service Level Agreement (SLA) metrics and performance guarantees as required by health plan clients.
• Participates and supports different committees and clinical rounds as necessary or assigned.