Director, Medicaid Clinical Programs

Alliant Health Solutions, Inc.•Louisville, KY

23h

About The Position

The Director, Medicaid Clinical Programs provides clinical and operational leadership across Alliant Health Solutions’ Medicaid contracts and programs. The role oversees contract-specific activities that may include prior authorization, utilization and clinical review, quality improvement, compliance, provider oversight, claims review, and program integrity. Applying clinical expertise, process improvement methods, and data analysis, the Director identifies risks and opportunities, translates requirements and findings into practical interventions, and works to improve access, quality, efficiency, compliance, and outcomes. The Director partners with clinical, programming, analytics, technology, and operations leaders to develop sustainable workflows. The position also collaborates with Program Directors, the Medical Director, and the Chief Operating Officer on new business opportunities and organizational initiatives, and serves as a presenter and thought partner with state Medicaid agencies. Knowledge of Medicaid delivery systems, including Fee-for-Service (FFS) and Managed Care Organizations (MCOs), is beneficial. Essential duties are routinely performed in a professional office environment, but may also take place remotely or in the field. The role may involve travel to customer locations and meetings. Core office or business operational hours may be required.

Requirements

Bachelor’s degree in nursing, public health, health administration, or a related field from an accredited college or university.
Seven to ten years of healthcare experience, including prior authorization, utilization review or management, or comparable clinical review operations.
Experience supporting multiple Medicaid programs or contracts in one or more relevant areas, including clinical review, quality improvement, provider oversight, compliance, claims review, or healthcare program integrity.
Demonstrated success leading measurable process improvements and using clinical and operational data to establish priorities, guide action, and evaluate results.
Strong understanding of healthcare quality measurement and improvement methodologies, with demonstrated ability to lead and collaborate across clinical, analytics, technology, and operations teams.
Strong knowledge of team leadership, prior authorization, clinical review workflows, medical necessity criteria, and applicable regulatory and accreditation requirements.
Broad knowledge of Medicaid clinical and operational functions, including utilization management, quality improvement, compliance, provider oversight, claims analysis, program integrity, and state Medicaid policy.
Ability to apply clinical knowledge and sound judgment, analyze clinical and operational data, identify trends and root causes, and translate complex findings into priorities and actions.
Excellent communication, interpersonal, facilitation, presentation, and critical-thinking skills, including the ability to communicate with nontechnical, executive, customer, and large-group audiences.
Ability to lead cross-functional teams, work effectively at all organizational levels, manage concurrent projects, and meet deadlines.
Proficiency with Microsoft Word, PowerPoint, and Excel.
Valid driver’s license and ability to travel by car or airplane to customer locations and meetings as needed.

Nice To Haves

Leadership experience in healthcare quality improvement, prior authorization, utilization management, or related operations.
Experience with Medicaid programs, MCOs, and Healthcare Effectiveness Data and Information Set (HEDIS) measures.
Clinical degree, licensure, or substantial clinical operations experience.
Master’s degree in nursing, public health, health administration, or a related health field.
National quality certification.

Responsibilities

Analyze clinical, operational, claims, quality, and performance data to identify trends, risks, compliance concerns, service gaps, root causes, and improvement opportunities across Medicaid programs.
Provide strategic oversight and subject matter expertise for prior authorization and related clinical operations, including medical necessity criteria, review workflows, timeliness, quality, regulatory and accreditation compliance, provider and member experience, and operational performance.
Lead contract-specific clinical and operational activities, which may include provider reviews and education, corrective-action follow-up, utilization and compliance reviews, claims review, provider oversight, and program integrity coordination.
Partner with analytics teams to turn data into actionable priorities, interventions, dashboards, measures, and analytic products; monitor results and adjust improvement strategies.
Lead process and quality improvement initiatives from assessment through implementation and monitoring to improve workflow reliability, turnaround times, clinical consistency, and outcomes.
Develop reports, recommendations, and presentations for executives, customers, state Medicaid agencies, and other stakeholders.
Collaborate with clinical, program, analytics, technology, and operations leaders to implement scalable, repeatable, and compliant processes and apply current clinical standards to program design, implementation, and evaluation.
Maintain current knowledge of Medicaid requirements and delivery models, including FFS and managed care, relevant to assigned programs, customers, and contracts.
Partner with Program Directors, the Medical Director, and the Chief Operating Officer on new business opportunities and organizational initiatives.
Identify predictive insights and opportunities for improvement and innovation, including appropriate use of AI tools to support analysis, workflow efficiency, and informed decision-making.
Present and act as a thought partner with state Medicaid agencies; support business development and contract teams through proposals, presentations, and strategic discussions.
Collaborate with organizational leaders to develop projects, improve operations, and strengthen Alliant’s credibility as a trusted advisor in Medicaid quality and performance improvement.
Model teamwork, professionalism, effective communication, positive behavior, appropriate presence, and compliance with corporate and departmental policies.
Protect information security and confidentiality in accordance with HIPAA, applicable laws and regulations, contract requirements, and company policies.
Perform other duties as assigned.