Your Future is our Future

At Lumeris, we believe that our greatest achievements are made possible by the talent and commitment of our team members. That's why we are actively seeking talented and collaborative individuals who are passionate about making a difference in the healthcare industry. Join us today as we strive to create a system of care that every doctor wants for their own family and become part of a community that values its people and empowers you to make an impact.

Position:

Sr. Director, Clinical Strategy and Operations

Position Summary:

This role is responsible for proactively developing and executing data driven strategies that support high value, cost effective, equitable member-centered care for our Medicare Advantage members. As a proven, results-oriented leader, this role will leverage deep and broad health plan clinical program development and utilization management expertise to drive efficient Prior Auth operations, building strategies and interventions to minimize member and provider abrasion. As the subject matter expert in the implementation of UM process improvements and technology solutions, this role will focus on reducing the administrative burdens while ensuring members get evidence-based coverage.
The Sr. Director will be action oriented and technically savvy. They are responsible for the achievement of organizational and departmental goals through vigorous monitoring of program and department metrics, review of data, and collaboration in researching literature to identify quality and cost containment opportunities.

Job Description:

Primary Responsibilities

Reporting to the SVP of Plan Operations, the Sr. Director will focus on the following key performance indicators:

Strategic, Operational and Financial:

• Drive clinical strategy in alignment with the Chief Medical Officer’s vision.
• In collaboration with the VP of Quality, Provider Performance team, and Provider Network Services team, proactively drive value through trusted relationships with provider partners.
• Partnering with claims and Medical Economics teams, 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.
• Serve as a key leader accountable for managing 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. Create use cases and test case scenarios.
• Prepare for and present clinical and UM insights and performance data to Medical Management Committee, Joint Operating Committee, Medical Director Committee, and Executive Leadership
• Assists in the negotiation of vendor contracts to maintain market relevance and support clients’ various benefit design requests. Collaborates to support provider contract negotiations, on-site audits, and ongoing monitoring of providers.

People Leadership:

 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.  Fosters accountability and collaboration to ensure team member and overall team success

Qualifications

• 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 mana