Director of Medical Management

COPE Health Solutions

11d•$140,000 - $180,000•Hybrid

About The Position

This individual operates with a high degree of autonomy, makes timely and confident decisions, and is deeply involved in operational details while maintaining accountability for outcomes, compliance, and client satisfaction in a fast-paced, high-growth environment. This role involves providing direct oversight and operational leadership for Utilization Management and Care Management programs, ensuring high-quality, compliance, and timely execution. The position requires ensuring consistent application of policies, procedures, and clinical criteria, monitoring program effectiveness, and driving continuous improvement. The Director will serve as an escalation point for complex issues, make decisive independent decisions, and ensure all clinical operations comply with federal, state, and accreditation requirements. Additionally, the role leads end-to-end client onboarding, supports quality improvement initiatives, develops and monitors key metrics, and drives operational excellence through process improvement, standardization, and automation. Collaboration with sales, clinical, operational, and IT teams is essential for delivering a consistent client experience.

Requirements

Bachelor’s degree in nursing, Healthcare Management, or related field, or equivalent experience.
8–12+ years of progressive experience in Utilization Management, Medical Management, Clinical Operations, or Healthcare Operations, including senior leadership responsibilities.
Deep, hands-on knowledge of UM operations, clinical criteria, and regulatory compliance.
Experience leading client implementations and ongoing managed services in a health plan, TPA, MSO, consulting, or health tech environment.
Proven ability to operate independently, manage ambiguity, and make timely, high-impact decisions.
Strong experience developing operational workflows, performance metrics, and scalable processes.

Nice To Haves

Clinical licensure (RN, MD, DO or equivalent) strongly preferred.
Strong Health plan operations knowledge.
Experience with Medicare, Medicaid, and/or commercial populations.
Knowledge of delegated UM arrangements and audit processes.
Experience working in or alongside technology-enabled clinical operations.

Responsibilities

Provide direct oversight and operational leadership for Utilization Management and Care Management programs and activities, ensuring high-quality, compliance, and timely execution.
Ensure consistent application of CM and UM policies, procedures, workflows, and evidence based clinical criteria for UM (e.g., MCG, LCDs, NCDs, medical necessity guidelines).
Monitor CM and UM program effectiveness and drive continuous improvement through data analysis, workflow optimization, and operational redesign.
Serve as an escalation point for complex clinical determinations, operational issues, and regulatory concerns, making decisive, independent decisions as needed based on the clinical operations model for a particular client or the CHS IPA/ACO.
Ensure all clinical operations comply with federal, state, and accreditation requirements, including delegated entity oversight and audit readiness.
Lead end-to-end onboarding for new and existing clients, including project planning, timeline management, performance improvement and coordination with internal and external stakeholders.
Ensure accurate setup of systems, workflows, and compliance requirements.
Conduct pre- and post-implementation reviews to guarantee smooth transitions.
Support quality improvement initiatives using objective and benchmark data, including utilization metrics, member outcomes, CAHPS, HEDIS, and Star Ratings where applicable.
Develop, implement, and monitor robust operational, clinical, and outcome metrics across UM, Care Management, and implementation activities.
Ensure services and deliverables are completed within expected timeframes and support internal and external quality audits.
Drive operational excellence through process improvement, standardization, automation, and scalable infrastructure.
Oversee clinical systems integrity, upgrades, customization, and reporting to ensure efficiency, data accuracy, and regulatory compliance.
Develop, review, and maintain clinical and operational policies and procedures aligned with current practices and regulatory requirements.
Partner with sales, clinical, operational, and IT teams to deliver consistent and exceptional client experience.
Coordinate internal resources for operational support.