Job Description:
• Develop and execute a comprehensive clinical strategy supporting medical cost management, quality performance, and member engagement goals
• Design end-to-end transitional care management programs for high-risk patients before hospitalization and transitions to appropriate care settings
• Design, implement, and refine evidence-based protocols and interventions for chronic disease management, predictive risk stratification, and SDOH tracking
• Lead cross-functional initiatives integrating clinical operations, population health, risk adjustment, and quality improvement
• Evaluate and recommend AI-driven triage, clinical decision support, remote monitoring, and telehealth technologies
• Collaborate with primary care providers and hospitalists to ensure timely communication and feedback
• Oversee clinical programs from concept design through pilot, rollout, evaluation, and scaling
• Establish KPIs and outcomes measurement frameworks; monitor performance and continuous quality improvement
• Integrate clinical analytics and predictive modeling to identify intervention opportunities and measure ROI
• Ensure alignment with CMS, HEDIS, CAHPS, HOS, Stars, and risk adjustment requirements
• Partner with provider networks and care management teams to enhance coordination and reduce avoidable utilization
• Ensure consistent execution of the clinical operating model across regions
• Lead a large geographically distributed team of clinicians, managers, and support staff
• Develop leaders in operational performance management, problem solving, and talent development
• Establish vendor expectations and metrics, monitor outcomes, and hold vendors accountable
• Develop standardized processes, workflows, and toolkits for clinical intervention delivery
• Implement process improvement methodologies and optimize resource utilization
• Drive adoption of technology and data solutions for precision targeting, automation, and real-time insights
• Manage accountability for programs, productivity, cost control, revenue growth, budgets, variances, and capital expenditure planning
• Advise executive leadership on population health, value-based care, and clinical innovation
• Build relationships with providers, vendors, and community partners
• Oversee staff recruiting, selection, orientation, training, workload assignment, performance appraisal, coaching, counseling, and performance management
Requirements:
• 5+ years of progressive leadership experience in care management, population health, or clinical operations, with a proven track record of managing operations under at-risk, ACO, or capitated payer contracts
• Deep understanding of Medicare Advantage regulations, Transitional Care Management (TCM), STARS and HEDIS metrics, and value-based care models
• Proven track record of developing and implementing scalable clinical programs that improve outcomes and reduce total cost of care
• Experience leveraging analytics and technology and embedding care management modules inside EHR systems
• Deep understanding of utilization management, care management, and risk adjustment functions
• Master’s degree (or higher) in Healthcare Administration, Nursing, Public Health, or related field
• Strategic thinker with strong execution discipline
• Excellent leadership, influence, and collaboration skills across cross-functional teams
• Strong analytical mindset and comfort interpreting clinical and financial data
• Exceptional communication and presentation abilities
• Demonstrated commitment to innovation, member-centric care, and continuous improvement
Benefits: