Lumeris · 1 day ago
Sr. Director, Clinical Strategy and Operations
United States
Full-time
Remote
Director/Executive
$154K/yr - $211K/yr
10+ years expLumeris is a company committed to transforming the healthcare industry through innovative strategies. The Sr. Director, Clinical Strategy and Operations will develop and execute data-driven strategies to enhance member-centered care for Medicare Advantage members, focusing on operational efficiency and clinical program development.
ConsultingHealth CareInformation Technology
Responsibilities
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
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
Qualification
Required
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 management
Superb leadership skills with the proven ability to guide, coach, develop, and motivate a large team
Excellent interpersonal and presentation skills with the ability to influence internally and externally and within all levels
Benefits
Medical, Vision and Dental Plans
Tax-Advantage Savings Accounts (FSA & HSA)
Life Insurance and Disability Insurance
Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)
Employee Assistance Program
401k with company match
Employee Resource Groups
Employee Discount Program
Learning and Development Opportunities
And much more...
Company
Lumeris
Lumeris is an accountable care delivery innovation company that offers operational support, technology, and consulting services.. It is a sub-organization of Essence Group Holdings.
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
$325.26MKey Investors
Deerfield
2024-04-10Series A· $100M
2023-11-06Debt Financing· $50M
2016-04-01Series Unknown· $80M
Leadership Team
Julie Hammes
SVP of People & Culture
David Carmouche
Executive VP and Chief Clinical Transformation Officer
Recent News
2025-11-05
Company data provided by crunchbase