The Director, Medicaid Clinical Operations provides clinical and operational leadership across the organization's portfolio of Medicaid contracts and programs. The role oversees and supports functions that may include prior authorization, utilization review, clinical review, quality improvement, compliance, and program integrity based on contract requirements. This role uses clinical knowledge, process improvement methods, and data analysis to identify opportunities, guide action, and improve access, quality, efficiency, compliance, and outcomes. The Director collaborates with program, clinical, analytics, technology, and operations leaders to translate contract requirements and performance findings into practical interventions and sustainable workflows.

Location: Ideally hybrid in the Atlanta area. Open to remote candidates with quarterly travel to Atlanta.

JOB FUNCTIONS:

• Leads and directs the analysis of clinical, operational, claims, quality, and performance data to identify trends, risks, compliance concerns, service gaps, and opportunities for improvement across Medicaid programs.
• Provides subject matter expertise and strategic oversight for prior authorization processes, including clinical review workflows, medical necessity criteria, timeliness, quality, and regulatory compliance.
• Evaluates prior authorization operations and clinical workflows to identify variation, barriers, risks, and opportunities to improve access, quality, efficiency, and the provider and member experience.
• Provides leadership and subject matter expertise for contract-specific clinical and operational activities, which may include provider reviews, provider education, corrective action follow-up, utilization and compliance review, and program integrity coordination.
• Partners with analytics teams to interpret clinical, operational, claims, and performance data and translate findings into clear, actionable insights, and data to establish priorities, recommend interventions, monitor results, and adjust improvement strategies.
• Leads process improvement initiatives using structured methodologies to improve workflow reliability, turnaround times, clinical consistency, and outcomes.
• Guides development of dashboards, measures, and analytic products that support clinical and operational decision-making.
• Develops clear reports, recommendations, and presentations for executives, customers, and other stakeholders.
• Collaborates with clinical, analytics, technology, and operations leaders to implement scalable, repeatable, and compliant processes.
• Apply quality improvement methodologies and current clinical standards to program design, implementation, and evaluation.
• Maintains awareness of Medicaid requirements and delivery models, including FFS and managed care, as relevant to assigned programs and customers.
• Collaborates with Program Directors, the Medical Director, and the Chief Operating Officer on new business opportunities and organizational initiatives.
• Identify predictive insights and forward-looking opportunities for improvement and innovation
• Serve as key presenter and thought partner in meetings with state Medicaid agencies
• Use AI tools to support analysis, workflow efficiency, and informed decision-making.
• Support business development and contract teams by contributing Medicaid expertise to proposals, presentations, and strategic discussions
• Enhance the organization's credibility as a trusted advisor in Medicaid quality and performance improvement
• Work in close collaboration with other leaders to support the development of new projects and the continuous improvement of the overall work of the organization.
• Promote core values of teamwork, professionalism, effective communication skills, and positive behavior.
• Maintain security and confidentiality of all information in accordance with HIPAA laws, regulations, and company policies.
• Perform other duties assigned.

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge and expertise with managing and leading a team, and prior authorization processes, 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 application of state Medicaid policy
• Knowledge of Medicaid delivery systems, including Fee-for-Service (FFS) and Managed Care Organizations (MCOs), is beneficial
• Knowledge of process improvement and quality improvement methodologies, with the ability to lead change from assessment through implementation and monitoring
• Ability to apply clinical knowledge and sound judgment to operational and quality improvement decisions
• Ability to analyze clinical and operational data, identify trends and root causes, and use findings to guide priorities and actions
• Excellent communication, interpersonal, facilitation, and problem-solving skills
• Ability to translate complex clinical, operational, and data findings for non-technical, executive, and customer audiences
• Ability to lead cross-functional teams and work effectively with all levels of the organization
• Ability to manage multiple activities and projects simultaneously and meet deadlines
• Proven success preparing and delivering presentations to small and large audiences
• Working knowledge of Medicaid data and delivery systems; managed care knowledge is preferred
• Proficiency with Microsoft Word, PowerPoint, and Excel
• Able to travel by plane or car as needed
• Must have valid driver's license with the ability to travel as needed by "driving" and/or "going on airplane to customer locations or meetings"

EDUCATION, EXPERIENCE, AND TRAINING

Required:

• Seven (7) to 10 years of healthcare experience, including significant experience with prior authorization, utilization review, utilization management, or comparable clinical review operations
• Leadership experience in healthcare quality improvement, prior authorization, utilization management, or related operations
• Experience supporting multiple Medicaid programs or contracts, including one or more areas such as prior authorization, utilization management, clinical review, quality improvement, provider oversight, compliance, claims review, or healthcare program integrity
• Demonstrated experience leading process improvement initiatives and implementing measurable changes in clinical or healthcare operations
• Demonstrated experience using clinical and operational data to identify priorities, guide action, and evaluate results
• Strong understanding of healthcare quality measurement and quality improvement methodologies
• Proven ability to lead and work effectively across clinical, analytics, technology, and operations teams
• Bachelor's degree in nursing, public health, health administration, or a related field from an accredited college or university

Preferred:

• 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 is a plus
• Experience with Medicaid programs, managed care organizations, and HEDIS measures

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, Los Angeles County Fair Chance Ordinance, and San Francisco Fair Chance Ordinance.