Vice President, Clinical Services & Operations

Medical Mutual; Cleveland (OH); On-site; USD 180,000 - 250,000; Full time

Benefits offered by this job

On-site fitness centers

Gym membership reimbursement

On-site cafeteria

Discounts for employees

Cash rewards program

Business casual attire

Job summary

Medical Mutual is seeking a Vice President of Clinical Services & Operations to lead Clinical Delivery teams and advance value-based care initiatives. You will report to the CMO and shape strategic clinical programs across priority areas including Prior Authorization, Acute and Post-Acute Care, and Case Management.

You will partner with leaders to optimize utilization, cost, quality, and member satisfaction, while guiding budget and communications to executives and stakeholders.

Qualifications

• RN with Ohio license required.
• 10 years progressive health care plan management experience including Medicare/Medicaid.
• Experience leading clinical delivery and value-based care initiatives.

Responsibilities

• Direct cross-functional teams to plan and implement division initiatives.
• Partner with VPs to advance clinical innovation and optimize strategies.
• Achieve medical management objectives for at‑risk populations.
• Promote cost-effective practice patterns with providers.
• Advise CMO on inquiries, communications and key meetings.
• Coordinate Division budget and prepare for CMO review.
• Oversee clinical content and program materials for utilization and case management.
• Oversee post-acute management of third-party providers.
• Represent Clinical Operations in customer and broker presentations.
• Perform additional duties as assigned.

Skills

Verbal communication

Written communication

Microsoft Office

Database reporting

Clinical systems

Strategic leadership

Budget management

Medicare knowledge

Provider engagement

Education

Bachelor's Degree in nursing or similar clinical area

Master's degree in Business or Health Care Administration or related field

Tools

N/A

Job description

Medical Mutual employees must submit their applications through MySource.

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

The Vice President of Clinical Services & Operations provides strategic leadership for the company's Clinical Delivery teams, including Prior Authorization, Acute and Post-Acute Care, Case Management, and Medicare Clinical Services. Reporting to the Chief Medical Officer (CMO), this leader shapes and executes high-impact clinical initiatives and develops executive communications that advance organizational priorities.

Responsibilities:

• Directs cross-functional teams through planning, development, evaluation, and implementation of Division initiatives across the organization and in collaboration with care delivery network and other business partners to achieve value-based outcomes including Medical Management, Clinical Operations, Provider Engagement, etc.
• Partners with VPs and business owners to advance clinical innovation and optimize strategies through process improvement, best practices, and performance analysis to improve utilization, cost, quality, and member satisfaction.
• Achieves medical management operational and financial objectives for all at risk patient populations (Medicare, Medicare Advantage, ACO and health plans).
• Promotes cost-effective practice patterns through interventions with healthcare providers.
• Serves as a strategic advisor to the CMO, managing clinical inquiries, communications, and key meetings while prioritizing critical issues to support informed and efficient decision-making.
• Coordinates Division budget and prepares for CMO review and approval.
• Oversees member, provider, and clinical communication materials and documents for clinical content and program accuracy for all products related to utilization and case management programs and services.
• Oversees post-acute management of third-party service providers to reduce variations in care and episode costs.
• Represents Clinical Operations as a subject matter expert in customer and broker presentations.
• Performs other duties as assigned.

Qualifications:

Education and Experience:

• Bachelor's Degree in nursing or similar clinical area of study required.
• Master's degree in Business or Health Care Administration or related field preferred.
• 10 years progressive health care plan management experience in multiple areas of clinical care management (utilization, case, or disease) or quality, and which includes government programs (Medicare, Medicaid)

Professional Certification(s):

• Registered Nurse with current State of Ohio unrestricted license required.

Technical Skills and Knowledge:

• Comprehensive knowledge of the health care continuum including population health, chronic condition management, provider reimbursement, and the ability to apply strategically.
• Comprehensive knowledge of applicable state, federal, and third-party regulations and the ability to apply advanced concepts to business operations.
• Strong knowledge of Medicare Advantage and other government program requirements.
• Knowledge of multiple commercial lines of business including Commercial Fully Insured, Self-Funded and Exchange products.
• Knowledge of profit and loss.
• Strong verbal and written communication skills including the ability to communicate ideas to leadership.
• Proficiency with Microsoft Office, database reporting, and clinical systems.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance - insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing. #LI-GR1

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

This employer is required to notify all applicants of their rights pursuant to federal employment laws.

For further information, please review the Know Your Rights notice from the Department of Labor.