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Director, Clinical Operations and Population Health - Emory Health Plan

Emory Healthcare/Emory University

Atlanta, GA(remote)

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JOB DETAILS
SKILLS
Affirmative Action, Analysis Skills, Behavioral Health, Benchmarking, Best Practices, Business Administration, Cardiology, Certified Case Manager (CCM), Chronic Renal Disease, Clinical Information Systems, Clinical Monitoring, Clinical Outcomes, Cost Control, Data Quality, Diabetes, Disease Prevention and Control, Federal Laws and Regulations, Finance, Financial Reporting, Gap Closure, Health Plan, Healthcare, Healthcare Effectiveness Data and Information Set (HEDIS), Hospital, Leadership, Literacy, Managed Care, Medications, Metrics, National Committee for Quality Assurance (NCQA), Obesity, Oncology, Pediatrics, Performance Analysis, Performance Reviews, Program Evaluation, Public/Media/Press/Analyst Relations, Quality Management, Quality of Care, Reconciliation, Registered Nurse (RN), Rehabilitation Act, Reporting Dashboards, Return on Investment (ROI), Risk, Service Level Agreement (SLA), State Laws and Regulations, Trend Analysis, Vendor/Supplier Evaluation, Work From Home
LOCATION
Atlanta, GA
POSTED
6 days ago


Discover Your Career at Emory University

Emory University is a leading research university that fosters excellence and attracts world-class talent to innovate today and prepare leaders for the future. We welcome candidates who can contribute to the excellence of our academic community.

Description

Director, Clinical Operations and Population Health serves as the clinical thought partner and operational deputy to the Senior Director through a true dyad partnership built on shared ownership of outcomes and genuine strategic co-leadership. Leads independently, makes decisions with authority, and represents EHP with full organizational credibility across all internal and external stakeholder relationships. KEY RESPONSIBILITIES: + Serves as the primary clinical execution partner for EHP's population health and VBC strategy, translating data-driven insights into actionable program priorities and measurable outcomes. + Drives strategy and execution across core clinical key results: cost trend management, high-cost member intervention, care management, utilization oversight, and HEDIS quality gap closure. + Leads high-priority clinical initiatives focused on chronic conditions, maternity/pediatric quality, ED/hospital utilization, behavioral health, among others, from program design through outcome measurement. + Stays current on VBC trends, benchmark EHP against high-performing peer plans, and brings evidence-based best practices into EHP's strategy on an ongoing basis. + Oversees UM activities in partnership with the TPA, including prior authorization oversight, level of care determination, clinical criteria application, and utilization trend monitoring. Leads complex patient case reviews for high-priority and high-cost members, providing clinical judgment, care plan direction, and escalation management. + Governs disease management programs across cardiac, oncology, behavioral health, MSK, diabetes, CKD, and obesity populations, ensuring protocol fidelity, outcome tracking, and quarterly review. + Oversees transitions of care protocols (post-discharge outreach, BH follow-up, medication reconciliation) and enforce care management partner SLA accountability. + Serves as EHP's primary clinical point of contact for all care management, UM, and care gap closure vendor partners, owning performance relationships end to end. + Conducts independent data validation of vendor-reported metrics, pulling underlying claims and utilization data to verify that reporting reflects clinical and financial reality. + Holds vendor partners accountable to contractual SLAs, lead formal performance reviews, escalate issues with documented remediation plans, and recommend program continuation or exit. + Oversees care gap closure partner performance on priority HEDIS measures, ensuring member outreach and provider engagement workflows translate into documented gap closure. + Navigates claims data, population health dashboards, and plan performance reports independently, while identifying trends, validating vendor data, and generating insights without analyst intermediary. + Translates complex data into clear executive narratives; build presentations that communicate program performance, financial impact, and strategic recommendations at all levels of the organization. + Evaluates program and vendor ROI by connecting clinical activity to PMPM trend movement, high-cost member spend reduction, and HEDIS improvement in terms that resonate with finance leadership. + Performs related duties as required. MINIMUM QUALIFICATIONS: + Active, unrestricted RN licensure in the State of Georgia. + Minimum 7 years of progressive clinical operations leadership in a health plan, managed care, or equivalent VBC setting. + Demonstrated track record leading population health programs: disease management, high-risk member intervention, care gap closure, and quality improvement. + Strong UM experience including prior authorization oversight, level of care determination, and TPA clinical operations oversight. + Proven ability to independently navigate claims data, population health dashboards, and financial reports without relying on analyst support. + Experience holding clinical vendors accountable to SLAs, conducting independent data validation, and leading formal performance reviews. PREFERRED QUALIFICATIONS: + Certified Case Manager (CCM) credential. + Master's degree (MSN, MBA, MHA, MPH, or equivalent). + Experience in a self-funded, direct-to-employer, or academic medical center health plan setting. + VBC contract literacy: shared savings mechanics, P4P design, episode bundles, and performance thresholds. + Behavioral health integration experience and BH network adequacy familiarity. NCQA accreditation readiness experience; TPA transition experience a meaningful plus. + Atlanta market knowledge and/or existing Emory Healthcare or Emory University relationships. NOTE: Position tasks are generally required to be performed in-person at an Emory University location. Remote work from home day options may be granted at department discretion. Emory reserves the right to change remote work status with notice to employee.

Additional Details

Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law. Emory University does not discriminate in admissions, educational programs, or employment, including recruitment, hiring, promotions, transfers, discipline, terminations, wage and salary administration, benefits, and training. Students, faculty, and staff are assured of participation in university programs and in the use of facilities without such discrimination. Emory University complies with Section 503 of the Rehabilitation Act of 1973, the Vietnam Era Veteran's Readjustment Assistance Act, and applicable executive orders, federal and state regulations regarding nondiscrimination, equal opportunity, and affirmative action (for protected veterans and individuals with disabilities). Inquiries regarding this policy should be directed to the Emory University Department of Equity and Civil Rights Compliance, 201 Dowman Drive, Administration Building, Atlanta, GA 30322. Telephone: 404-727-9867 (V) | 404-712-2049 (TDD). Emory University is committed to ensuring equal access and providing reasonable accommodations to qualified individuals with disabilities upon request. To request this document in an alternate format or to seek a reasonable accommodation, please contact the Department of Accessibility Services ataccessibility@emory.eduor call 404-727-9877 (Voice) | 404-712-2049 (TDD). We kindly ask that requests be made at least seven business days in advance to allow adequate time for coordination.

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Job Number

_166404_

Job Type

_Regular Full-Time_

Division

_Executive Vice President_

Department

_Emory Health Plan_

Job Category

_Care Management_

Campus Location (For Posting) : Location

_US-GA-Atlanta_

_Location : Name_

_Emory Campus-Clifton Corridor_

Remote Work Classification

_Primarily On Campus_

Health and Safety Information

_Not Applicable_

About the Company

E

Emory Healthcare/Emory University