Clinical Ops Director, Medical Management

HealthEZ • Edina, MN

18d • $95,000 - $120,000

About The Position

The Clinical Director, Medical Management & Advocacy provides day-to-day clinical leadership and operational oversight for Utilization Review (UR), Case Management (CM), and Advocacy programs. This role partners closely with a Senior Clinical Director to execute strategy, ensure regulatory compliance, optimize clinical workflows, and deliver high-quality, member centered care. The Clinical Director serves as a key clinical leader supporting internal teams, vendor partners, and cross functional stakeholders.

Requirements

• Active clinical license required, with preference for RN/LPN or LCSW.
• 7+ years of experience in Medical Management, Clinical Operations, Utilization Review, or Case Management.
• Demonstrated experience overseeing clinical programs, workflows, and vendor performance.
• Strong understanding of regulatory requirements, HIPAA, and medical necessity processes.

Nice To Haves

• Experience in a TPA, health plan, or managed care environment.
• Experience leading operational transformation or scaling clinical programs.
• Familiarity with URAC, NCQA, or similar accreditation standards.

Responsibilities

• Medical Management Program Oversight Oversee the operational performance of Medical Management programs, including Utilization Review, Case Management, and Advocacy.
• Ensure consistent execution of program workflows, service standards, and clinical protocols across internal teams and vendor partners.
• Partner with the Senior Clinical Director to implement clinical strategy through operational processes and program design.
• Vendor & Operational Management Manage day-to-day Utilization Review and Case Management vendor operations, including performance monitoring, reporting, and issue resolution.
• Review vendor metrics, and quality indicators; identify and address performance gaps.
• Coordinate clinical escalations and large claimant workflows in collaboration with vendor partners and internal stakeholders.
• Policy, Compliance & Governance Own and maintain Medical Management policies and procedures, ensuring operational alignment and regulatory compliance.
• Serve as the organization’s HIPAA Officer for Utilization Review, Case Management, and Advocacy functions.
• Support audits, accreditation activities, and regulatory reviews as they relate to Medical Management operations.
• Team Leadership & Enablement Provide operational leadership and guidance to advocacy and clinical care teams, ensuring clarity of roles, workflows, and expectations.
• Support workforce planning, training, and operational readiness for Medical Management programs.
• Oversee 24/7 clinical helpline operations, including coverage models, escalation protocols, and quality oversight.

Benefits

• Employee benefits are part of the competitive total rewards package that HealthEZ provides to you.
• Our comprehensive benefits program includes health benefits, retirement plan (401k), paid time off, paid leave including parental leave and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: No Education Listed