Director, Care Management

This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Director, Care Management in United States.

This role is a senior clinical leadership position focused on transforming how care is managed within a modern health plan environment. You will lead the design and execution of case management and utilization management strategies to ensure members receive high-quality, evidence-based, and cost-effective care. Operating at the intersection of clinical practice and payer operations, you will help translate medical necessity, coverage policies, and population health insights into real-world member outcomes. The position requires close collaboration with cross-functional teams including operations, underwriting, analytics, product, and care delivery teams. You will play a key role in shaping clinical and cost strategies that directly influence affordability, access, and quality of care. This is a high-impact opportunity for a clinically grounded leader who wants to improve healthcare experiences at scale.

• Lead the payer-side clinical strategy, ensuring coverage policies, utilization management decisions, and clinical guidelines are evidence-based and aligned with high-quality member care.
• Build and manage a clinician-led care management function focused on complex case management, utilization review, and high-cost patient oversight.
• Develop and implement cost containment and value-based initiatives that improve outcomes while maintaining affordability and reducing unnecessary care variation.
• Define and evolve coverage policies, benefit structures, and formulary guidelines in alignment with clinical best practices and business goals.
• Collaborate with pharmacy partners to design programs that control drug spend while maintaining adherence and minimizing member friction.
• Partner with underwriting, actuarial, and analytics teams to evaluate clinical risk, support pricing strategies, and generate actionable population health insights.
• Work closely with network, product, and care delivery teams to identify gaps in care and inform contracting and service design decisions.
• Serve as a clinical expert in the development of internal payer tools, workflows, and decision-support systems.
• Establish performance metrics for care management programs and continuously evaluate clinical outcomes, cost efficiency, and member impact.

Requirements:

• Active clinical license (NP, RN, PA, MD, or DO) and/or Master’s degree in Healthcare Administration or related field.
• 8+ years of experience combining hands-on clinical practice with payer-side experience in case management, utilization management, or population health.
• Strong understanding of healthcare delivery, clinical decision-making, and payer operations, with the ability to balance cost, quality, and access.
• Experience working in or with startup or fast-paced healthcare environments is highly desirable.
• Strong analytical mindset with comfort working with data, reporting tools, and basic analytics platforms.
• Ability to communicate complex clinical and financial concepts clearly across clinical, technical, and business stakeholders.
• Demonstrated ability to build programs, processes, or teams from the ground up in evolving environments.
• Strong judgment, adaptability, and comfort operating with ambiguity in a rapidly changing organization.
• Excellent collaboration, communication, and stakeholder management skills.
• Deep motivation to improve healthcare systems and deliver better outcomes for members and employers.

Benefits:

• Fully remote-first organization with no office return requirements.
• Comprehensive medical, dental, and vision insurance with 100% employee coverage.
• Flexible vacation policy and strong emphasis on work-life balance.
• 401(k) retirement plan with company match, plus FSA and HSA options.
• Paid parental leave and disability/life insurance coverage.
• Equity (stock options) offered to all employees.
• Continuing education support, including licensure renewal and CEU sponsorship.
• Home office setup stipend and ongoing learning and development budget.
• Paid sabbatical after five years of service.
• Transparent compensation structure with clear career development pathways.
• Competitive base salary ranging from $155,000 to $175,000 plus equity.