Director, Clinical Performance

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

This role is a senior clinical operations leadership position focused on overseeing delegated utilization management and care management activities across multiple health plan clients within Medicaid and managed care environments. You will be responsible for ensuring the consistent application of evidence-based clinical guidelines in authorization, review, and medical necessity determinations. The position plays a critical role in maintaining operational excellence, regulatory compliance, and high-quality clinical decision-making across utilization management workflows. You will lead day-to-day clinical operations while partnering closely with medical directors, compliance, and analytics teams to improve performance and identify care optimization opportunities. This is a highly hands-on leadership role combining operational oversight with direct involvement in clinical review processes. The environment is fast-paced, regulated, and mission-driven, with a strong focus on population health and care quality improvement.

In this role, you will oversee utilization management operations and ensure high-quality clinical decision-making across delegated health plan services.

• Lead day-to-day utilization management operations, including case review workflows, authorization decisions, and turnaround time management
• Ensure consistent application of evidence-based clinical guidelines and medical necessity criteria in all review processes
• Support authorization, denial, and appeals processes while maintaining performance standards and regulatory compliance
• Partner with medical directors to resolve complex clinical cases and ensure appropriate escalation pathways
• Oversee staffing models, workload distribution, and operational workflows to maintain efficiency and service levels
• Participate in internal and external audits and ensure compliance with regulatory, accreditation, and contractual requirements
• Maintain and update utilization management policies and procedures in alignment with regulatory changes
• Collaborate with analytics teams to support data governance and clinical performance measurement frameworks
• Identify trends in utilization patterns including overutilization, underutilization, and site-of-care inefficiencies
• Work closely with compliance teams to ensure timely response to regulatory updates and policy alignment

Requirements:

This role requires extensive experience in clinical operations, population health management, and utilization management leadership within complex healthcare environments.

• Bachelor’s degree required; Master’s degree in nursing, healthcare administration, or related field preferred
• Active and unrestricted Registered Nurse (RN) license in California required
• 10+ years of experience in population health management or clinical operations
• Proven experience leading teams in remote and matrixed healthcare environments
• Strong background in utilization management, case review processes, and clinical decision support
• Experience working with Medicaid, managed care, or delegated health plan services strongly preferred
• Deep understanding of clinical guidelines, evidence-based practice, and regulatory requirements
• Strong leadership, communication, and stakeholder management skills
• Experience in program development and operational process improvement
• Analytical mindset with ability to interpret clinical and operational performance data
• Commitment to patient-centered care and regulatory compliance excellence

Benefits:

• Competitive annual salary range of approximately $127,803 to $191,704 depending on experience and qualifications
• Comprehensive health, dental, and vision insurance coverage
• Life and disability insurance benefits
• 401(k) retirement savings plan with employer matching
• Paid time off and paid holidays
• Remote work flexibility (California or Pacific Time Zone based)
• Opportunity to lead high-impact clinical performance programs in population health
• Inclusive and mission-driven work environment focused on healthcare transformation