Director, Clinical Operations and Population Health - Emory Health Plan

Emory•Atlanta, GA

1d•Hybrid

About The Position

The Director, Clinical Operations and Population Health serves as the clinical thought partner and operational deputy to the Senior Director through a dyad partnership built on shared ownership of outcomes and strategic co-leadership. This role leads independently, makes decisions with authority, and represents Emory Health Plan (EHP) with full organizational credibility across all internal and external stakeholder relationships. The position is primarily responsible for the clinical execution of EHP's population health and Value-Based Care (VBC) strategy, translating data-driven insights into actionable program priorities and measurable outcomes. Drives strategy and execution across core clinical key results including 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, and others, from program design through outcome measurement. Stays current on VBC trends, benchmarks EHP against high-performing peer plans, and integrates evidence-based best practices into EHP's strategy. Oversees Utilization Management (UM) activities in partnership with the Third-Party Administrator (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 various populations (cardiac, oncology, behavioral health, MSK, diabetes, CKD, and obesity), ensuring protocol fidelity, outcome tracking, and quarterly review. Oversees transitions of care protocols (post-discharge outreach, BH follow-up, medication reconciliation) and enforces care management partner Service Level Agreement (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 reporting accuracy. 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, identifying trends, validating vendor data, and generating insights without an analyst intermediary. Translates complex data into clear executive narratives and builds presentations to communicate program performance, financial impact, and strategic recommendations. Evaluates program and vendor ROI by connecting clinical activity to PMPM trend movement, high-cost member spend reduction, and HEDIS improvement.

Requirements

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.

Nice To Haves

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.

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, benchmark 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, lead formal performance reviews, escalate issues with documented remediation plans, and recommend 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; build 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.
Performs related duties as required.