**Resp & Qualifications** **NOTE:** We are looking for an experienced leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week. **PURPOSE:** Under leadership of the Executive Vice President, Health Services, this position leads and oversees Case Management, Utilization Management including prior authorization, and post service clinical medical review and Appeals & Grievances operational functions for all lines of business. The Vice President of Clinical Operations is accountable for both behavioral health and medical care management at all stages of the health continuum, utilization management decisions themselves and the consequences of those decisions by way of appeals, for all lines of business that result in demonstrable impacts to health outcomes, cost of care, and member experience. Promotes and supports the corporate mission affordable, equitable access to high quality healthcare services for our members and communities. Leads the development of clinical and diagnostic clinical operations strategy. The Vice President will lead and build a team of clinical operations professionals who oversee the strategy for implementation and execution of best-in-class clinical programs. Ensures compliance with all regulatory guidelines and provides expert advice, advocacy and counsel to executive and administrative leadership. Represents the company interfacing with healthcare delivery partners, vendors and other key external constituents and stakeholders. **ESSENTIAL FUNCTIONS:** + Utilization Management & Application of Nationally Recognized Medical Policy: Drives the efficiency and effectiveness of the companys UM program, specifically pertaining to Prior Authorization end to end process including timely notification / requests from providers, driving efficiency through movement from fax to portal technology, consistency in application of clinical guidelines (Milliman Care Guidelines (MCG)/medical policy), ongoing MCG training, referrals for physician reviews, review and determination of procedures requiring prior authorization, review and determination of procedures to sunset authorization requirements and strong KPI/operating metrics management. Ensuring that all requirements and standards pertaining to prior authorization meet all Federal, State and NCQA requirements. + Appeals, Grievances & Clinical Medical Review: Oversees the Appeals and Grievance function as well as Clinical Medical Review for both pre-payment and post-payment stages. + Directs and ensures the efficient operational management of member appeals and grievance departments/function with emphasis on execution, outcomes, continual improvement and performance enhancement. Oversees risk assessment and mitigation activities, as well as regulatory compliance. + Oversees the Pre-Payment Clinical Medical Review function aimed at controlling and managing claims that were denied with reason codes that have a clinical component to them such as medical necessity, cosmetic, or experimental / investigational and more. Oversees Post-Claim Medical Review function aimed at controlling and managing claims that were denied with reason codes that have an administrative component to them such as ""no auth on file,"" but there can be others involving member benefits. Ensures that claims are reviewed for proper editing methodology and trends tracked and that clinicians are effectively partnering with Medical Directors for review and sign off. + Medical and Behavioral Health Care Management: Provides oversight and integration of Medical and Behavioral Health Case Management / member care coordination. Ensures we have application of best-in-class ID & Stratification and Population Health approach to case management and care coordination for all LOBs. This entails management oversight of all Case Management clinical teams (including member clinical assessments, use of Health Risk Appraisals, development of member care plans and goals as well as care coordination for short term and long-term case management along with specialized case management such as Maternity, Cancer, etc.), Case Management Training and the clinical platform that supports this function. Collaborates with Clinical, Behavioral and Pharmacy departments ensuring that all requirements and standards pertaining to prior authorization meet all Federal, State and NCQA requirements. + Quality Improvement: Participate with the activities of key corporate quality committees including Quality Improvement Advisory Committee, Credentialing Advisory Committee, Care Management Committee, Medical Policy/Technology Assessment Committee, Delegation Oversight Committee, Pharmacy & Therapeutics Committee, and other committees and task forces as appropriate. + Strategic Development: Oversees the strategic and the day-to-day activities of the team, including directing, coaching, and guiding associates to implement departmental, divisional, and organizational mission/goals. Recruits, retains, and develops a high performing team. Leads operations with a command of key performance indicators, leverages technology to optimize cost per unit / case, measures and reports on the impact of clinical operations activities. Evaluates performance of each team member and sets goals within the context of the corporate policies and procedures. Develops, monitors, and analyzes variances of departmental budgets to control and appropriately allocate resources. **SUPERVISORY RESPONSIBILITY:** This position manages people. **QUALIFICATIONS:** **Education Level:** Bachelor's Degree in Nursing, Healthcare, Business or related degree with a focus on operations and/or clinical education with additional business and/or operational training. **Experience:** 10 years of health plan operations experience and 5 years administrative executive leadership experience in a managed care setting. Previous experience as clinic for a health care company. At least 5 years as a leader of people, large operating budgets, and large teams. **Preferred Qualifications:** + MBA, RN or MD/DO. + Previous experience at the Vice President level for a health care company and/or payer organization with deep operations experience. + Working knowledge of both commercial and government programs lines of business. + In depth knowledge of clinical operations and regulatory compliance related to utilization management. **Knowledge, Skills and Abilities (KSAs)** + Proficient in utilization management processes, quality assurance standards, and managed care. + Strong people management and leadership experience in a clinical environment. + Ability to manage operations with an extensive and varied scope. + Writes and presents effectively; adjusts to fit the audience and the message; strongly gets a message across. + General understanding of health care claims data, trend analysis, and insurance operations and products. + Skilled in coordinating and collaborating with physicians and other internal and external stakeholders including regulatory agencies, media, state and local health department leaders, and more. + Demonstrated application and knowledge of current and emerging practice guidelines. + Experience using data to make data driven business decisions. + Ability to interpret and implement federal, state and local guidelines for all aspects of the member and provider process. + Ability to review and analyze procedures and workflows and to make process streamlining recommendations. + Demonstrated ability to lead and motivate staff; and affect change.Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging. **Salary Range:** $275,360 - $413,040 **Salary Range Disclaimer** The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements). **Department** Health Services Leadership **Equal Employment Opportunity** CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. **Where To Apply** Please visit our website to apply: www.carefirst.com/careers **Federal Disc/Physical Demand** Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs. **PHYSICAL DEMANDS:** The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted. **Sponsorship in US** Must be eligible to work in the U.S. without Sponsorship \#LI-SS1 REQNUMBER: 20130