Director, Clinical Management

Key Responsibilities

• Lead the Clinical Management function, including delegated clinical operations, clinical pathway enablement, and specialist network management.
• Establish a coordinated, member-centered approach to Clinical Management that aligns delegated clinical operations with the Blue Zones Health Ecosystem of Care.
• Develop the long-term vision for Clinical Management as a strategic organizational capability that advances prevention, coordinated care, and whole-person health.
• Build scalable workflows that integrate delegated clinical operations with Clinical Operations, Well-Being Services, Provider Engagement, and Medical Directors.
• Continuously evolve traditional managed care functions into a Lifestyle-Informed Clinical Management model that strengthens prevention, improves chronic disease management, and supports value-based care.
• Foster a culture of collaboration, accountability, operational excellence, innovation, and continuous improvement.
• Lead all delegated clinical operations in compliance with CMS requirements, health plan standards, delegation agreements, and regulatory requirements.
• Oversee prior authorization operations, including workflow design, medical necessity review, criteria application, turnaround time performance, and operational excellence.
• Lead concurrent review, inpatient utilization management, and appeals operations.
• Develop and manage staffing models, workforce schedules, and resource allocation plans that ensure appropriate coverage and operational performance across delegated clinical functions.
• Maintain compliance with all delegated function requirements and monitor operational performance, productivity, quality, turnaround times, and service levels across delegated functions.
• Standardize policies, procedures, documentation standards, and workflows that promote consistency, quality, and operational efficiency.
• Identify opportunities to simplify processes, reduce administrative burden, and improve the experience for providers, members, and internal teams.
• Ensure members receive clinically appropriate review based on evidence-based medical necessity criteria.
• Partner with Medical Directors to continually refine clinical pathways and review processes.
• Analyze utilization trends, referral patterns, denials, appeals, and emerging clinical signals to identify opportunities for improving clinical decision-making.
• Design, develop, and continuously improve evidence-based clinical pathways that ensure members receive the right care, at the right time, through the most appropriate clinical pathway.
• Transform authorizations, referrals, admissions, ED utilization, concurrent reviews, quality gaps, new diagnoses, utilization trends, and emerging clinical signals into opportunities for earlier intervention.
• Generate actionable clinical intelligence that informs prevention strategies, chronic disease management, population health initiatives, and future pathway development.
• Host regular cross-functional case conferences to review identified members and defined pathways.
• Work closely with the Provider Engagement & Activation Director to strengthen PCP-specialist collaboration, improve referral experiences, and inform specialist recruitment and network development.
• Collaborate with the Vice President of Well-Being Services to ensure clinical pathways are successfully operationalized through member engagement, care management, care coordination, lifestyle pathways, and closed-loop communication.
• Champion the Blue Zones Health philosophy by ensuring delegated clinical operations contribute to prevention, coordinated care, improved management of chronic disease through lifestyle-informed care, and better member outcomes.

Requirements

• Registered Nurse (RN) or other licensed clinical professional with an active, unrestricted license.
• Minimum of 7 years of progressive leadership experience in Clinical Management, Medical Management, Utilization Management, Managed Care, or Delegated Clinical Operations.
• Demonstrated experience leading prior authorization, concurrent review, appeals, delegated clinical functions, and multidisciplinary clinical teams working onshore and offshore.
• Strong knowledge of healthcare regulations, policies, and standards.
• Excellent communication and interpersonal skills.
• Ability to lead and mentor a high-performing team.
• Experience in developing and implementing scalable workflows and standard operating procedures.
• Proven ability to analyze data and translate insights into actionable strategies.
• Strong analytical and problem-solving skills.
• Ability to collaborate effectively with cross-functional teams.
• Knowledge of clinical pathways and utilization management.