Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” 

 

The Vice President of Population Health & Clinical Support leads the development and execution of Capital’s Population Health Strategy across all lines of business (LOB), with a strong focus on Government Programs (Medicare Advantage & ACA products). This role ensures that population health interventions are strategically measured and coordinated to optimize clinical outcomes, total cost of care, and member satisfaction, particularly in high-impact segments with significant P&L opportunities. This role reports to the CMO & Senior Management, ensuring that all population health strategies align with Capital’s overarching business objectives.

Strategic Leadership and Cross-Functional Collaboration

• Works closely with clinical, business, and provider teams to integrate population health efforts into Capital’s Value Proposition, ensuring alignment with Government Programs, Provider Networks, Payment Integrity, and Marketing.
• Provides strategic and operational leadership to enhance HEDIS and STARs performance and optimize P&L outcomes for Government Programs through targeted population health management strategies. Collaborate cross-functionally to drive the development of innovative clinical interventions that support organizational goals and improve outcomes in key populations.
• Leads the RFP/Sales Support team, guiding clinical responses and presentations while advising the Product Team on clinical program evaluations.

Quality and Cost Optimization

• Drives improvements in HEDIS and STARs ratings, enhances Total Cost of Care management, supports Risk Adjustment strategies, and ensures strong financial performance across LOBs.
• Supports Medical Informatics, Actuarial, and Cost of Care teams in analyzing utilization trends, evaluating clinical programs, and guiding outcomes methodology.
• Utilizes system technology for clinical tracking and implementation, leads priority initiatives, and assesses risks affecting clinical program success.

Operational Oversight & Compliance

• Ensures adherence to Population Health Management standards in partnership with the Accreditation Unit, oversees delegated vendor activities, and supports internal education on population health initiatives.
• Works with Accreditation, Quality Improvement Committees, and internal teams to ensure standards and quality measures are met for population health initiatives.
• Supports the Population Health Management Strategy across all lines of business (LOBs), with a strong emphasis on key programs such as Medicare Advantage.
• Partners with vendors to deliver population health management services, ensures contractual and delegation requirements are met, and collaborates with internal teams to optimize interventions.

Corporate and Community Engagement

• Actively participates in Total Cost of Care Leadership, strategic planning, and corporate initiatives, while representing Capital in the medical provider community and supporting Sales and Marketing efforts.

Skills: 

• Demonstrated public speaking and written communication skills.
• Computer literate with the ability to process requests on-line.
• Microsoft applications; outlook, word, excel, visio, project proficient.
• Problem solving and critical thinking skills with ability to determine best approach.
• Team player; ability to work cross-functionally.
• Mentor/coaching skills.
• Leadership: Able to work effectively with all areas of the company, providing clinical and organizational leadership. Excellent interpersonal skills and professional demeanor. Ability to drive action and results on a cross functional basis.

Knowledge:

• Knowledge of Medicare coverage criteria and online tools available to remain current.
• Knowledge of HEDIS, Stars, CAHPS, and other Quality/CMS requirements and health plan   measures in commercial and government business.
• Knowledge of current and emerging medical treatment modalities relevant to specific populations including Medicare Advantage.
• Knowledge of NCQA requirements, CMS and state and federal requirements.
• Knowledge of workload planning and staff management concepts.
• Knowledge of productivity monitoring and tools.
• Knowledge of Implementation process and management.

Experience:

• At least five years’ experience in managed care, population health management, and/or quality management with particular focus on driving performance of government programs/products including Medicare Advantage and Individual/ACA .
• Minimum of five to seven years’ experience in a management or leadership position in the health care industry.
• Demonstrated success in driving P&L model improvement within key populations/products
• PC literacy and ability to perform electronic research and respond to electronic requests

Education, Certification and Licenses:

• Master’s degree or greater in a healthcare management or related field required.
• Evidence of education or certification in population health management.
• Current valid Pennsylvania drivers’ license to travel to and from provider/member/customer locations.

Location: 

• This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays. 

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
• The employee must occasionally lift and/or move up to 5 pounds.

 

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.