Senior Director, Clinical Strategy and Operations
Lumeris
full-time
Posted on:
Location Type: Remote
Location: United States
Visit company websiteExplore more
Salary
💰 $153,800 - $210,650 per year
Job Level
About the role
- Drive clinical strategy in alignment with the Chief Medical Officer’s vision.
- Proactively drive value through trusted relationships with provider partners.
- Leverage data driven insights to curate prior authorization lists, identify impactful clinical programs, and adjust Policies and Procedures to align with key business strategies.
- Establish baseline targets, comparative analysis and benchmarks, and dynamic performance dashboards for key prior authorization metrics.
- Provide clinical and operational expertise towards the design or selection of clinical programs, including utilization of vendor partnerships.
- Manage appropriate, evidence-based medical utilization and cost for Part B and Part C benefits while managing departmental budget.
- Lead CMS compliant Utilization Management teams, processes, reporting, and related audits.
- Lead Prior Auth or UM related technical implementations as the business owner/SME, building buy-in and ensuring people and process readiness for seamless transitions.
- Prepare for and present clinical and UM insights and performance data to Medical Management Committee, Joint Operating Committee, Medical Director Committee, and Executive Leadership.
- Assist in the negotiation of vendor contracts to maintain market relevance and support clients’ various benefit design requests.
- Collaborate to support provider contract negotiations, on-site audits, and ongoing monitoring of providers.
- Mentors, motivates, supports, and develops nurses and administrative staff. Guides SMART goal setting/review, regular guidance and 1-1 check ins, career development/planning, upskilling, resource allocation, staffing, budget management, DE&I initiatives, and other People & Culture programs/activities as needed.
Requirements
- Bachelor's degree or equivalent
- Registered Nurse with a Missouri State license
- 10+ years of relevant experience or the knowledge, skills, and abilities to succeed in the role
- 7+ years of health plan leadership experience or the knowledge, skills, and abilities to succeed in the role
- Ample managed care experience and expert knowledge of state and federal insurance programs; experience with Medicare Advantage required, and D-SNP preferred.
- Evidence of data driven, systems thinking; advanced problem-solving, and critical thinking skills with the proven ability to identify, develop, communicate, implement, and guide process improvements and strategic initiatives
- Clear evidence of fiscal management including P&L, resource allocation, and contract/vendor management
- Superb leadership skills with the proven ability to guide, coach, develop, and motivate a large team
- Excellent interpersonal and presentation skills with the ability to influence internally and externally and within all levels.
Benefits
- Medical, Vision and Dental Plans
- Tax-Advantage Savings Accounts (FSA & HSA)
- Life Insurance and Disability Insurance
- Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)
- Employee Assistance Program
- 401k with company match
- Employee Resource Groups
- Employee Discount Program
- Learning and Development Opportunities
- And much more...
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical strategyprior authorizationutilization managementdata analysisperformance metricsbudget managementvendor managementcontract negotiationevidence-based medicineMedicare Advantage
Soft Skills
leadershipmentoringcoachinginterpersonal skillspresentation skillsproblem-solvingcritical thinkingcommunicationteam developmentstrategic initiative guidance
Certifications
Bachelor's degreeRegistered NurseMissouri State license