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Director, Clinical Management

2 days ago

La Crescenta

Job DescriptionDescription: POSITION SUMMARY The Director of Clinical Management leads the Blue Zones Health Clinical Management function, serving as the bridge between delegated clinical operations and the BZH Ecosystem of Care. Reporting to the Vice President of Well-Being Services, and working closely with the Chief Clinical Officer, Medical Directors, and the Provider Engagement Director, and Clinical Operations (Success) Manager, the Director ensures clinical events and signals are translated into coordinated action. The role provides operational leadership for delegated clinical functions while continuously evolving those functions into a strategic capability that strengthens prevention, improves chronic disease management, and advances whole-person care. The role ensures every clinical event and emerging clinical signal - from an authorization request to a hospital admission, from a new diagnosis to a rising-risk member, becomes an opportunity to identify unmet needs, define the most appropriate clinical pathway, and enable the right teams to act. WHAT WE ARE BUILDING BZH is building a coordinated, clinically supervised ecosystem of care that treats chronic disease at its origin. Every part of the organization works around a single member, against a single care plan, with full visibility across every layer: • Primary care physicians and specialists providing coordinated clinical oversight, • Clinical pathways connecting members to the right care at the right time, • Well-Being Services activating lifestyle change, preventive care, and chronic disease management between clinical visits, • Community prescriptions linking members to local resources and social supports, with closed-loop reporting back to the care team, • Virtual programs spanning lifestyle, movement, nutrition, and stress management, • Community organizations woven into the fabric of care The Director of Clinical Management defines the most appropriate clinical pathway that connects members to the right combination of clinical care, lifestyle support, and community resources. This role identifies members who need earlier intervention before their condition worsens and ensures that the clinical insights generated through delegated operations continuously inform the work of Well-Being Services, Clinical Operations, and the broader care team. Every clinical event and emerging signal becomes an opportunity to improve a member's health trajectory. THE QUESTION THIS ROLE ANSWERS "What is the most appropriate clinical pathway for this member, and how do we enable the right team to act?" KEY RESPONSIBILITIES 1. Clinical Management Leadership • Lead the Clinical Management function, including delegated clinical operations, clinical pathway enablement, and specialist network management, • Establish a coordinated, member-centered approach to Clinical Management that aligns delegated clinical operations with the Blue Zones Health Ecosystem of Care, • Develop the long-term vision for Clinical Management as a strategic organizational capability that advances prevention, coordinated care, and whole-person health, • Build scalable workflows that integrate delegated clinical operations with Clinical Operations, Well-Being Services, Provider Engagement, and Medical Directors, • Continuously evolve traditional managed care functions into a Lifestyle-Informed Clinical Management model that strengthens prevention, improves chronic disease management, and supports value-based care, • Foster a culture of collaboration, accountability, operational excellence, innovation, and continuous improvement 1. Delegated Clinical Operations • Lead all delegated clinical operations in compliance with CMS requirements, health plan standards, delegation agreements, and regulatory requirements, • Oversee prior authorization operations, including workflow design, medical necessity review, criteria application, turnaround time performance, and operational excellence, • Lead concurrent review, inpatient utilization management, and appeals operations, • Develop and manage staffing models, workforce schedules, and resource allocation plans that ensure appropriate coverage and operational performance across delegated clinical functions., • Monitor workload, capacity, productivity, and staffing needs to proactively adjust resources and support organizational growth., • Ensure consistent application of evidence-based clinical criteria including InterQual, MCG, and health plan policies, • Ensure delegation audit readiness and maintain compliance with all delegated function requirements, • Monitor operational performance, productivity, quality, turnaround times, and service levels across delegated functions, • Standardize policies, procedures, documentation standards, and workflows that promote consistency, quality, and operational efficiency, • Identify opportunities to simplify processes, reduce administrative burden, and improve the experience for providers, members, and internal teams 1. Clinical Review & Medical Director Partnership • Ensure members receive clinically appropriate review based on evidence-based medical necessity criteria, • Coordinate Medical Director review for escalated medical necessity determinations, complex clinical cases, and appeals requiring physician-level review, • Develop standardized review workflows, escalation pathways, and clinical governance processes, • Ensure consistent application of medical policies, clinical guidelines, and utilization management criteria across the organization, • Partner with Medical Directors to continually refine clinical pathways and review processes, • Analyze utilization trends, referral patterns, denials, appeals, and emerging clinical signals to identify opportunities for improving clinical decision-making 1. Clinical Pathway Enablement • Design, develop, and continuously improve evidence-based clinical pathways that ensure members receive the right care, at the right time, through the most appropriate clinical pathway, • Develop pathway rules, clinical triggers, and decision frameworks that identify when members should be referred to Well-Being Services, specialists, community resources, or additional clinical support, • Integrate lifestyle medicine, prevention, Well-Being Services, and community resources into disease-specific and population-specific pathways, • Develop standardized referral, escalation, transition-of-care, and care coordination pathways across the Blue Zones Health Ecosystem, • Use utilization trends, quality data, clinical outcomes, and emerging clinical signals to evaluate and continuously improve pathway effectiveness, • Ensure clinical pathways support seamless transitions between primary care, specialty care, Clinical Operations, Well-Being Services, and community-based services, • Partner with Medical Directors, Clinical Operations, and Well-Being Services to ensure pathways remain evidence-based, coordinated, scalable, and member-centered, • Develop new clinical pathways as Blue Zones Health expands into additional conditions and populations 1. Specialist Referral Management • Work with the Network Build team to ensure the specialist network supports the clinical pathways established by Blue Zones Health, • Design and optimize referral workflows that promote timely access, continuity of care, coordinated communication, and closed-loop referrals, • Monitor specialist referral performance, referral completion, specialist access, network utilization, communication effectiveness, and referral outcomes, • Evaluate specialist quality, member experience, referral appropriateness, and practice variation to identify opportunities for improvement, • Identify specialty access gaps and operational barriers that impact member care and recommend solutions, • Partner with the Provider Engagement & Activation Director to strengthen PCP-specialist collaboration, improve referral experiences, and inform specialist recruitment and network development, • Recommend preferred referral pathways and specialist partnerships that improve clinical outcomes and member experience, • Ensure specialist referrals reinforce the member's overall clinical pathway 1. Clinical Intelligence, Prevention & Lifestyle-Informed Care • Transform authorizations, referrals, admissions, ED utilization, concurrent reviews, quality gaps, new diagnoses, utilization trends, and emerging clinical signals into opportunities for earlier intervention, • Develop clinical triggers that proactively identify members who would benefit from Well-Being Services, lifestyle pathways, community prescriptions, care management, or additional clinical support, • Generate actionable clinical intelligence that informs prevention strategies, chronic disease management, population health initiatives, and future pathway development, • Identify opportunities to improve the management of chronic disease through lifestyle-informed care and coordinated clinical pathways, • Host regular cross-functional case conferences to review identified members and defined pathways, • Use delegated clinical operations as a strategic source of insight to reduce avoidable utilization and improve long-term health outcomes, • Partner with Well-Being Services to ensure clinical intelligence is translated into timely member engagement and intervention 1. Cross-Functional Collaboration • Partner with Clinical Operations by providing utilization trends, referral insights, and clinical intelligence that support quality improvement, documentation integrity, RAF accuracy, provider education, coding initiatives, and provider performance, • Establish feedback loops that ensure delegated clinical operations continuously inform provider education, RAF optimization, quality improvement, coding opportunities, and population health strategy, • Partner with the Vice President of Well-Being Services to ensure clinical pathways are successfully operationalized through member engagement, care management, care coordination, lifestyle pathways, and closed-loop communication, • Collaborate with the Provider Engagement & Activation Director to improve provider workflows, referral experiences, specialist collaboration, and provider adoption of Blue Zones Health clinical pathways, • Work closely with Medical Directors on complex clinical determinations, pathway development, utilization trends, and delegated function oversight, • Collaborate across executive leadership to ensure the Blue Zones Health Ecosystem of Care functions as a coordinated, integrated model 1. Leadership, Workforce Planning & Operational Excellence • Lead, mentor, develop, and retain a high-performing Clinical Management team, • Build a culture defined by clinical rigor, operational excellence, collaboration, accountability, innovation, and continuous learning, • Establish meaningful performance metrics and accountability across delegated clinical operations, • Develop scalable operating models, workflows, standard operating procedures, and governance structures that support organizational growth, • Promote continuous improvement by using operational data, clinical intelligence, member outcomes, and team feedback to strengthen performance, • Foster strong partnerships across Clinical Operations, Well-Being Services, Provider Engagement, Medical Directors, and executive leadership, • Develop future leaders and organizational capabilities that support the continued evolution of the Clinical Management function, • Champion the Blue Zones Health philosophy by ensuring delegated clinical operations contribute to prevention, coordinated care, improved management of chronic disease through lifestyle-informed care, and better member outcomes Requirements: QUALIFICATIONS Required • Registered Nurse (RN) or other licensed clinical professional with an active, unrestricted license, • Minimum of 7 years of progressive leadership experience in Clinical Management, Medical Management, Utilization Management, Managed Care, or Delegated Clinical Operations, • Demonstrated experience leading prior authorization, concurrent review, appeals, delegated clinical functions, and multidisciplinary clinical teams working onshore and offshore, • Strong knowledge of CMS regulations, Medicare Advantage, delegation requirements, InterQual, MCG, and evidence-based medical necessity criteria, • Demonstrated success designing scalable clinical operations and improving operational performance, • Strong understanding of value-based care, population health, chronic disease management, utilization management, and care coordination, • Experience building cross-functional partnerships across clinical, operational, provider-facing, and member-facing teams, • Passion for prevention, whole-person care, lifestyle-informed care, and improving health outcomes through innovative care delivery models Preferred • Experience in Medicare Advantage, delegated entities, IPAs, ACOs, risk-bearing medical groups, or value-based care organizations, • Experience in Lifestyle Medicine, population health, or chronic disease management, • Familiarity with Blue Zones principles, behavior change, and whole-person care models, • Experience implementing technology-enabled clinical workflows, care management platforms, utilization management software, CRM systems, or population health analytics platforms, • Certification in CPHM, CCM, ACM, or equivalent

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