What are the responsibilities and job description for the VP Clinical Operations position at UPMC?
Purpose:
Reporting to the CMO of Commercial Products and Clinical Operations, the VP, Clinical Operations is accountable and responsible for end-to-end care management and utilization management, from design to operations, to evaluation and continuous improvement, meeting the needs of providers and supporting member population health. The position is an executive leader within the Population Health (Clinical) organization of the UPMC Insurance Services Division. A critical requirement of the new VP, Clinical Operations is broad experience across health plan environments, including a strong working knowledge and perspective on utilization of AI and/or automation of processes and technology to support effectiveness, efficiency, and satisfaction of the care management and utilization management staff. An additional competency is the ability to develop and implement a mature staffing model, for both clinical and non-clinical associates, to deliver exceptional services, interactions, and outreach to providers and members. The ideal candidate has experience leading the development of new models, methods, and innovations which enhance health outcomes and affordability of products and services delivered by the Plan to members, providers, and other stakeholders.
Responsibilities:
- Key leader, decision maker, and catalyst for overall strategic development and operations of care management, care coordination, utilization management, and appeals and grievances to achieve the Quadruple Aim and UPMC's population health mission.
- Develop an understanding of the local healthcare landscape, provider network, and home and community resources to look for key drivers and opportunities for innovative care models.
- Develop an understanding of the unique health needs and attributes of the populations served to drive development of programs and services.
- Utilize analytics to identify key insights about the populations served to develop interventions that target unique populations and/or medical management standards of care.
- Overall responsibility to lead the team to create strategic care management programs and operationalize, lead, and monitor those programs and use them to coordinate with providers, members, families and caregivers, community, regulators, and stakeholders.
- Leadership, direction, and oversight for staffing, processes, technology, and operations for all UM functions (prior authorization, concurrent review, appeals and grievances) to ensure effective medical management to deliver high quality care to our members.
- Experience at aligning LTSS UM processes performed by the care management or utilization management team to the overarching medical and service management framework and operations.
- Lead the strategic advancement away from health plan utilization management working toward clinical decision-making and medical management by providers, especially given the unique relationship with UPMC providers as an integrated payvider.
- Work collaboratively with the health plan's Medical Directors and product leads in achieving cost of care targets and mitigate trends.
- Adhere to and exemplify the leadership values and behaviors of UPMC for staff to model.
