The Director, Medicaid Clinical Operations provides clinical and operational leadership across the organization's portfolio of Medicaid contracts and programs. The role oversees and supports functions that may include prior authorization, utilization review, clinical review, quality improvement, compliance, and program integrity based on contract requirements. This role uses clinical knowledge, process improvement methods, and data analysis to identify opportunities, guide action, and improve access, quality, efficiency, compliance, and outcomes. The Director collaborates with program, clinical, analytics, technology, and operations leaders to translate contract requirements and performance findings into practical interventions and sustainable workflows.
Location: Ideally hybrid in the Atlanta area. Open to remote candidates with quarterly travel to Atlanta.
JOB FUNCTIONS:
- Leads and directs the analysis of clinical, operational, claims, quality, and performance data to identify trends, risks, compliance concerns, service gaps, and opportunities for improvement across Medicaid programs.
- Provides subject matter expertise and strategic oversight for prior authorization processes, including clinical review workflows, medical necessity criteria, timeliness, quality, and regulatory compliance.
- Evaluates prior authorization operations and clinical workflows to identify variation, barriers, risks, and opportunities to improve access, quality, efficiency, and the provider and member experience.
- Provides leadership and subject matter expertise for contract-specific clinical and operational activities, which may include provider reviews, provider education, corrective action follow-up, utilization and compliance review, and program integrity coordination.
- Partners with analytics teams to interpret clinical, operational, claims, and performance data and translate findings into clear, actionable insights, and data to establish priorities, recommend interventions, monitor results, and adjust improvement strategies.
- Leads process improvement initiatives using structured methodologies to improve workflow reliability, turnaround times, clinical consistency, and outcomes.
- Guides development of dashboards, measures, and analytic products that support clinical and operational decision-making.
- Develops clear reports, recommendations, and presentations for executives, customers, and other stakeholders.
- Collaborates with clinical, analytics, technology, and operations leaders to implement scalable, repeatable, and compliant processes.
- Apply quality improvement methodologies and current clinical standards to program design, implementation, and evaluation.
- Maintains awareness of Medicaid requirements and delivery models, including FFS and managed care, as relevant to assigned programs and customers.
- All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, Los Angeles County Fair Chance Ordinance, and San Francisco Fair Chance Ordinance.