Director of Clinical & Cost Containment, Employee Benefits

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 arrangements Pri