Director of Clinical Services

NTT DATA•Irvine, CA

2d•Hybrid

About The Position

The Director of Clinical Services leads the Clinical Services function, overseeing case management, disease and chronic condition management, clinic services, mobile health initiatives, virtual health utilization, wellness and population health programs, and medical vendor relationships under a single accountable leader. This role is responsible for proactively managing healthcare costs while improving member health outcomes and experience. The Director serves as the strategic and clinical leader of an integrated care model that connects case management, utilization management, clinical programs, provider networks, and health data to identify high-risk populations, improve care coordination, and drive measurable outcomes. The Director collaborates with clinical advisors, operational leaders, data and analytics teams, underwriting, account management, and external healthcare partners to develop and execute strategies that enhance quality of care, improve member engagement, and demonstrate value to employer groups and other stakeholders.

Requirements

7 to 10 years of progressive healthcare experience, including at least 5 years in leadership within a health plan, managed care organization, accountable care organization, provider network, healthcare system, or integrated delivery model.
Minimum 5 years of demonstrated success developing, implementing, and managing clinical programs such as case management, disease management, utilization management, population health, wellness, or medical management initiatives.
Active clinical license required, as Nurse Practitioner (NP) or Physician Assistant (PA)
Bachelor's Degree or higher
Bilingual, English & Spanish required

Nice To Haves

Preferred Bilingual Spanish proficiency.
Proven success building and scaling clinical operations, managing internal teams and external vendors, and driving measurable clinical and financial outcomes.
Experience evaluating, selecting, negotiating, and managing outsourced healthcare vendors and clinical service providers.
Strong understanding of healthcare claims data, utilization management, care coordination, risk identification, and performance measurement.
Demonstrated ability to collaborate effectively with operations, analytics, finance, underwriting, account management, and executive leadership teams.
Experience working with employer-sponsored health plans, self-funded health programs, population health strategies, or value-based care initiatives.
Experience supporting culturally diverse and underserved populations.

Responsibilities

Design and manage a comprehensive case management program for high-cost and medically complex members, ensuring appropriate care in the most effective setting.
Oversee utilization management and pre-authorization review processes as part of the overall case management strategy.
Implement proactive outreach efforts to identify and engage high-risk members early in their healthcare journey.
Develop and oversee programs focused on chronic conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, and other high-impact health conditions.
Coordinate care for members with complex or high-cost health needs to reduce avoidable hospital admissions and readmissions.
Support medication adherence and advocacy initiatives that improve health outcomes.
Drive utilization of clinic-based, mobile health, and virtual care services by connecting members to the most appropriate care setting.
Develop reporting and visibility into utilization trends, outcomes, member engagement, and program value.
Lead wellness, prevention, and population health initiatives, including biometric screening programs and chronic disease outreach.
Design and implement member education campaigns focused on preventive care and healthy lifestyle behaviors.
Increase engagement among underserved or disengaged populations and improve access to primary care services.
Serve as the clinical owner of healthcare vendor relationships, including care delivery organizations, virtual health providers, specialty clinical programs, and other medical service partners.
Establish clinical performance expectations, oversee quality and member experience outcomes, and ensure accountability across vendor partnerships.
Provide clinical guidance related to provider networks, healthcare access, site-of-care decisions, pharmacy benefits, specialty medications, and utilization management strategies.
Evaluate prospective vendors and clinical programs based on quality, outcomes, and value, while leading build-versus-buy assessments.
Develop and facilitate ongoing performance reviews using clinical quality measures, operational metrics, and cost outcomes.
Provide clinical guidance and support for healthcare service expansion initiatives, including clinic and mobile health operations.
Partner with underwriting and risk management teams to evaluate population health risks and high-cost claimants.
Support employer group reporting and renewal discussions by translating clinical interventions, engagement activities, care gap closure efforts, and health outcomes into meaningful business insights.
Contribute to community health initiatives, member outreach programs, and health education efforts.
Lead and develop multidisciplinary clinical teams, including case managers, community health workers, health educators, and other clinical staff.
Establish caseload standards, clinical protocols, quality measures, and operational best practices.
Determine the optimal balance of internal staffing, contracted services, and outsourced clinical programs.
Collaborate with physician advisors and clinical leadership to ensure medical alignment and quality oversight.
Develop member identification models using claims data, diagnosis and procedure codes, pharmacy information, utilization patterns, and clinical program data.
Support integration efforts across healthcare vendors, data platforms, and health information exchange systems.
Define and monitor key performance indicators (KPIs), including engagement rates, admissions, readmissions, emergency department utilization, quality metrics, and healthcare cost trends.
Present outcome reports and recommendations to executive leadership and key stakeholders.
Represent the organization professionally through written, verbal, and visual communications.
Travel as needed to attend meetings, events, training sessions, or operational site visits.
Perform additional duties, projects, and assignments as required.