Director of Medical Management

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.

Clinical Operations
• 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.
Client Implementation & Onboarding
• 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.
Quality, Metrics & Performance Management
• 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.
Operational Excellence & Infrastructure
• 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.

Cross-Functional Collaboration
• Partner with sales, clinical, operational, and IT teams to deliver consistent and exceptional 
client experience.
• Coordinate internal resources for operational support.
Qualifications
• 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.

Preferred Qualifications
• 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.

Core Competencies
• Strategic thinking and operational excellence
•Client-centric approach with a focus on service quality
•Leadership and team development
•Analytical and process improvement mindset
•Adaptability in a fast-paced environment

Benefits:
As a firm passionate about health care, we’re deeply committed to the health and wellness of 
our own team members. We offer comprehensive, affordable insurance plans for our team and 
their families, and a host of other unique benefits, such as a yearly stipend for wellness-related 
activities and a paid parental leave program. You can learn more about our benefits offerings 
here: https://copehealthsolutions.com/careers/why-cope-health-solutions/.

About COPE Health Solutions
COPE Health Solutions is a national tech-enabled services firm powering success for health 
plans and for providers in risk arrangements. Our comprehensive NCQA certified population 
health management platform and highly experienced team brings deep expertise, experience, 
proven tools, and processes to improve financial performance and quality outcomes for all 
types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and 
improves quality and financial performance for providers, health plans and self-insured 
employers. For more information, visit CopeHealthSolutions.com.

To Apply:
To apply for this position or for more information about COPE Health Solutions, visit us at 
https://copehealthsolutions.com/careers/open-positions/.