Vice President, Clinical Services & Operations

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.

• 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.

• 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)

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

• 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:

• 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,…