Clinical Ops Director, Medical Management

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.

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.

• 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.

Preferred

• 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.

We make healthcare EZ!

Additional Opportunity Details:

Target Base Compensation Range for this role is $95,000-$120,000*

*Factors that may be used to determine your actual salary include your job specific skills, education, training, job location, number of years of experience related to this role and comparison to other employees already in this role. *

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.

HealthEZ recognizes its responsibilities under federal, state and local laws requiring non-discriminatory employment practices. All employment decisions, practices and procedures will be carried out without regard to race, color, creed, religion and sex (including pregnancy), sexual orientation, national origin or ancestry, age, marital status, disability, family status, status with regard to public assistance or any other characteristic protected under applicable local, state and federal laws.

HealthEZ is proud to be an equal opportunity employer.

Salary : $95,000 - $120,000