VP, Medicaid Clinical Operations
About the role
The VP, Medicaid Clinical Operations is an enterprise executive responsible for leading Medicaid clinical operations, utilization management, care management/service coordination, and clinical program delivery across Medicaid markets. This leader translates Medicaid strategy, market requirements, quality priorities, and regulatory expectations into standardized operating models, scalable workflows, measurable performance outcomes, and ensures operational excellence.
Key Responsibilities
Lead Medicaid Clinical Operations, including clinical and nonclinical teams supporting utilization management, care management/service coordination, program operations, process improvement, training, and project execution.
Establish clear operating rhythms, accountability structures, workforce productivity expectations, and performance management processes across distributed clinical operations teams.
Build and sustain an engaged, high-performing leadership culture focused on associate development, retention, operational discipline, and measurable outcomes.
Develop and execute Medicaid clinical operations strategies that support growth, market expansion, state contract requirements, enterprise priorities, and scalable operating model transformation.
Translate clinical strategy, market commitments, and program designs into operational workflows, staffing models, performance targets, and implementation plans.
Lead operational readiness and implementation for new Medicaid markets, expanded programs, and enterprise transformation initiatives.
Drive standardization, workflow optimization, and continuous improvement to improve scalability, consistency, and performance across markets.
Oversee Medicaid utilization management and care management/service coordination functions, ensuring consistent clinical practices, regulatory compliance, timely decision-making, and appropriate escalation management.
Advance integrated care models that address physical health, behavioral health, long-term services and support, social needs, and complex population health needs.
Strengthen care navigation, member access, provider coordination, and interventions that reduce avoidable utilization and improve health outcomes.
Partner with physician leadership, nursing leadership, behavioral health, quality, market, Medicare, and functional teams to align clinical programs and support dual-eligible and complex member populations.
Partner with Finance to manage budgets, staffing models, labor efficiency, investment priorities, and operating performance.
Identify performance gaps, assess clinical and operational risk, and implement mitigation plans, corrective actions, and sustainable performance improvement routines.
Partner with Medicaid markets, Medicare, Quality, Compliance, Legal, Finance, Product, Technology, Analytics, Provider, Behavioral Health, LTSS, and enterprise operations teams to deliver integrated clinical outcomes and ensure operational needs are reflected in enabling capabilities.
Guide partnerships with providers, home and community-based services organizations, vendors, and other external partners to support member-centered, high-quality care delivery.
Represent Medicaid Clinical Operations in executive forums, business reviews, client or state-facing discussions, transformation governance, and performance reviews.
Drive consistent, high-quality clinical operations across Medicaid markets while enabling growth, innovation, operational excellence, and regulatory readiness.
Advance whole-person, integrated care for Medicaid members by connecting strategy, clinical expertise, analytics, operating discipline, and effective cross-functional partnership.
Develop a strong clinical operations leadership pipeline and culture of accountability, collaboration, engagement, and continuous improvement.
Qualifications
Bachelor’s degree required; advanced degree in nursing, public health, healthcare administration, business administration, social work, or a related field preferred.
Strongly preferred Clinical license, nursing degree, or other healthcare credential; MD is not required.
10 plus years of progressive experience in Medicaid, managed care, clinical operations, utilization management, care management, population health, health services operations, or healthcare transformation.
5 plus years leading large, distributed clinical and/or operational teams, including leaders of leaders, through scale, change, and performance improvement.
Deep understanding of Medicaid programs, state contract requirements, regulatory expectations, integrated care models, LTSS, behavioral health, complex populations, and DSNP coordination.
Demonstrated ability to translate strategy into operational execution, standardized workflows, measurable outcomes, and sustainable performance improvement.
Experience partnering with Product, Technology, Data, and Analytics teams to translate clinical operations needs into business requirements, workflow priorities, reporting needs, user adoption considerations, and measurable solution outcomes preferred.
Strong financial acumen, including experience managing budgets, staffing models, productivity, labor efficiency, revenue, margin, and operating performance.
Prioritized proven ability to lead through ambiguity, influence cross-functionally, manage risk, engage senior stakeholders, and communicate effectively with executive audiences.