As VP of Clinical Programs, you will provide strategic leadership and clinical expertise across key domains of our business, including third-party administration (TPA) of health benefits, utilization management, payment integrity, and population health management. This physician leader will play a pivotal role in ensuring that members receive appropriate, high-quality care while optimizing the use of resources and ensuring accurate, compliant payment processes for our clients. You will work in close partnership with our Senior Director of Care Navigation and other clinical, operational, and corporate leads to set the strategic medical management and affordability agenda for our TPA. You will report to our SVP of Product who is also is our Chief Clinical Officer.

What you'll do:

• Lead clinical programs in population health, utilization management, and payment integrity, ensuring alignment with the organization’s goals of improving healthcare outcomes and improving costs.
• Serve as the primary clinical point of contact for internal teams and external stakeholders, including clients, network and program partners.
• Develop and implement best practice guidelines and policies to guide clinical decision-making.
• Maintain understanding of competitive landscape and serve as internal and occasional external-facing thought leader
• Collaborate with other clinical leaders to develop clinical strategy
• Partner with sales and client success to support their functions and deeply understand our customers and channel partners’ clinical needs
• Direct programs and product development needs that support members in navigating the healthcare system efficiently and affordably.
• Oversee the development and implementation of tools and services that help guide patients through care transitions and complex medical needs, ensuring they access the right care at the right time.
• Provide clinical leadership for UM activities, ensuring that medical services are used appropriately and in accordance with best practices.
• Lead efforts to review medical necessity and benefit coverage, focusing on balancing cost-efficiency with member care quality.
• Collaborate with medical management teams to oversee appeals and case reviews, ensuring compliance with relevant regulations.
• Lead clinical efforts to ensure accurate claim payments, identifying areas of risk for inappropriate billing or fraud.
• Serve as the clinical expert in discussions related to medical coding, billing, and fraud detection.
• Work closely with senior leadership, operational teams, and external partners to align clinical strategies with organizational objectives.
• Foster strong relationships with internal and external partners to drive innovation and continuous improvement in clinical programs.
• Utilize data analytics to measure the effectiveness of clinical programs, identifying opportunities for improvement and ensuring compliance with quality metrics.
• Develop and present performance reports to senior leadership, recommending strategies to enhance clinical outcomes and financial performance.
• Ensure all clinical programs comply with relevant healthcare regulations.
• Serve as the clinical representative in regulatory audits, policy reviews, and compliance discussions.

To be successful in this role, you'll need:

• MD or DO degree, active clinical license
• 10+ years clinical experience with 5+ years in healthcare leadership role, preferably in a TPA, health plan, or accountable care organization
• Proven track record of driving healthcare value
• Experience in complex servicing or operations leadership environments
• Clinical domain expertise with a broad knowledge of industry business clinical operations, in particular within the employer sponsored benefits space
• Demonstrated success influencing operational process improvement and performance management
• Data-driven decision-maker with the ability to establish and analyze key performance metrics, assess program outcomes, and develop evidence-based strategies for improvement.
• Excellent planning, presentation, and decision-making skills
• Outstanding communications, leadership, and interpersonal skills
• Solid business acumen, analytical, and inquisitive
• Strong emotional intelligence and ability to lead through influence
• Ability to effectively collaborate and execute in a highly matrixed environment

Pay Transparency Statement

This is a hybrid position based out of one of our offices: San Francisco, CA, Plano, TX, or Lehi, UT. Hybrid employees are expected to be in the office three days per week (Plano, TX) or two days per week (San Francisco, CA and Lehi, UT). #LI-hybrid

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.