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Vice President Clinical Service - Utilization Management & Appeals Oregon, Washington, Idaho, Utah Primary Job Purpose The Vice President Clinical Services is a member of the Health Services Organization (HSO) leadership team focused on enabling members to achieve their best health by simplifying their care journey, improving quality, supporting providers in their delivery of care, and managing total cost. The VP of Clinical Services is accountable for clinical functions which may include care management, transition of care services, medical policy development and implementation, utilization management, facility stay reviews and appeals. This role helps shape and drive strategy and execution in support of integrated business solutions aligned to the needs of each health plan line of business (e.g. Medicare, individual, ASO, etc.). The position oversees internal programs and external vendors and plays a key role in medical cost stewardship and ensuring clinical quality of services to members. General Functions and Outcomes * Provides leadership in developing, implementing, and communicating short and long-range plans, goals and objectives for the function. * Aligns team goals with the organization's vision and strategy. * Develops strategies and tactics to effectively manage healthcare costs and improve clinical quality across all product lines. * Partners with leaders and stakeholders across the enterprise to prioritize activity and solutions in support of medical management strategies and operational plans. * Develops, recommends, and implements clinical and operational policies and procedures. * Develops and manages performance against business, financial, utilization, and operational metrics to ensure results are achieved across clinical services functions and various Lines of Business. * Analyzes and uses information and data to guide the development and implementation of new or enhanced health care interventions that improve value to the member and payers. * Ensures programs meet federal and state regulations, accreditation standards, quality metrics, client requirements and evolving models of care (e.g. accountable care organizations, patient centered homes). * Determines appropriate staffing levels and resource needs, creates and manages department and/or project budgets, allocates resources and approves expenditures. * Fosters an effective work environment and ensures employees receive appropriate communication, recognition, and professional development. * Participates in organizational talent management and succession planning. Minimum Requirements * Expertise related to health insurance industry trends, evolving accountable care and payment models, case and utilization management programs and how to best partner with providers to achieve desired outcomes. * Strong communication and facilitation skills with all levels of the organization, including the ability to resolve issues and build consensus among groups of diverse internal/external stakeholders. * Strong leadership, negotiation and relationship building skills. * Deep business acumen including understanding of market dynamics, financial/budget management, data analysis and decision making. * Demonstrated competency related to creating and executing business strategies and driving results within a large, complex organization and/or with external partners. * Proven ability to implement and execute successful business transformation and lead through change. * Proven ability to develop a high performing team and manage and develop leaders. The Vice President Clinical Services would have a bachelor's degree in business management, health administration or a related field, 10 years of management/leadership experience and five years of e To view the full job description,