Director, Clinical Operations and Population Health - Emory Health Plan

About the role

The Director, Clinical Operations and Population Health at Emory University serves as the clinical thought partner and operational deputy to the Senior Director, fostering a dyad partnership where both parties share ownership of outcomes and engage in strategic co-leadership.

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, benchmarks 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, leads formal performance reviews, escalates issues with documented remediation plans, and recommends 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; builds 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.

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.