Director of Clinical & Cost Containment, Employee Benefits

About this role

Position Summary

The Director of Clinical & Cost Containment is a senior strategic role within Strategic Benefit Resources (SBR) responsible for leading the clinical consulting and cost containment program capabilities that differentiate SBR's self-funded solutions in the wholesale distribution market. This individual serves as the primary clinical subject matter expert across SBR's book of business, partnering with sales, distribution, and stop-loss consulting teams to evaluate, implement, and communicate clinical cost containment strategies that drive measurable financial outcomes for employer clients.

This role bridges clinical expertise and consultative sales support — working directly with broker/consultant partners, TPAs, stop-loss carriers, and employer plan sponsors to identify high-cost claim drivers, optimize vendor program selection, and develop clinical frameworks that reduce plan cost and improve member outcomes.

Why This Role Exists

As the self-funded benefits market grows increasingly complex — driven by specialty drug spend, catastrophic claim frequency, and heightened employer demand for transparency — SBR's distribution model requires dedicated clinical leadership to: • Evaluate and validate cost containment vendor solutions (Rx carve-outs, case management, utilization review, reference-based pricing, direct contracting) presented to clients

• Provide clinical oversight and credibility in stop-loss consulting engagements

• Identify coverage gap risks (e.g., Rx carved out of medical stop-loss) and proactively protect clients and SBR's risk profile

• Position SBR as a value-added clinical advisory resource to differentiate from transactional wholesale competitors

Key Responsibilities Clinical Cost Containment Strategy • Lead the development and ongoing refinement of SBR's clinical cost containment framework, aligning strategies with market trends and client needs

• Evaluate, vet, and recommend cost containment vendors and programs (utilization management, case management, pharmacy benefit management, transplant networks, reference-based pricing, direct primary care, etc.)

• Analyze claims data, clinical utilization trends, and high-cost claimant profiles to identify actionable savings opportunities

• Monitor medical cost trends, specialty drug pipelines, and catastrophic claim drivers to proactively advise clients and sales teams

Stop-Loss Carrier Support / Claims Support • Review TPA trigger reports and claim referrals to surface impending high-cost diagnoses and recommend clinical risk mitigation actions

• Identify and communicate coverage gap risks when Rx is carved out of stop-loss contracts or when benefit plan design creates clinical exposure

• Serve as clinical liaison between SBR, stop-loss carriers, TPAs, and employer plan sponsors on complex claims and risk management issues

Consulting & Distribution Enablement • Support SBR's sales and consulting teams with clinical presentations, client-facing materials, and technical talking points for broker/consultant audiences

• Conduct clinical reviews and plan analyses for prospective and existing employer clients, translating clinical findings into financial impact narratives

• Develop educational resources, webinars, and market-facing content that position SBR's clinical expertise as a competitive differentiator

• Partner with distribution leadership and brokers/consultants to align cost containment program recommendations with individual client risk profiles and plan designs

Vendor Management & Program Oversight • Build and maintain relationships with clinical cost containment vendors, including case management firms, utilization review organizations, PBMs, and specialty program providers

• Evaluate vendor performance through KPI monitoring, outcome tracking, and savings validation

• Negotiate program terms and coordinate seamless integration of clinical vendors within the SBR distribution ecosystem

• Stay current on regulatory developments, ERISA compliance requirements, and clinical best practices affecting self-funded plan design

Internal Leadership & Collaboration • Partner with the Chief Strategy Officer, COO, and sales leadership to align clinical strategy with SBR's overall growth objectives

• Provide clinical training and education to internal SBR teams, ensuring consultants can confidently represent cost containment solutions

• Contribute to the development of SBR's strategic plan as it relates to clinical program expansion, new vendor partnerships, and market positioning

Qualifications

Required • Bachelor's degree in Nursing, Healthcare Administration, Health Sciences, or a related clinical field; RN license strongly preferred

• 5+ years of experience in clinical cost containment, case management, utilization management, stop-loss, or self-funded health plan consulting

• Deep knowledge of self-funded employer benefit plan design, stop-loss insurance structures, and the TPA/wholesale distribution market

• Demonstrated understanding of medical coding (ICD-10, CPT), clinical guidelines, and claims adjudication processes

• Experience working with or evaluating cost containment vendors including case management, PBMs, reference-based pricing, and specialty drug management programs

• Strong analytical and data interpretation skills; ability to translate clinical findings into financial and strategic insights

• Excellent communication, presentation, and relationship management skills with broker, consultant, and employer-level audiences

Preferred • Certification in Case Management (CCM), Certified Employee Benefit Specialist (CEBS), or equivalent professional credential

• Experience with pharmacy carve-out structures and Rx cost containment programs in the self-funded context (e.g., PMPM guarantee models, closed formulary programs)

• Familiarity with all types of self funded arrangements including captive insurance structures, level-funded plans, or consortium-based stop-loss arr

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