Dir, Strategic Clinical Operations & Population Health

Summary :
Directs all functions and activities related to clinical operations, utilization management, care management, and population health at SummaCare. This includes leadership of Care Management, Utilization Management, and Intake teams, as well as population health initiatives related to Care Coordination and Condition Management Programs. Responsible for driving measurable reductions in medical cost trend, eliminating operational inefficiencies, deploying technology to scale program impact, and leading large-scale change management initiatives. Works closely with Medical Directors to ensure clinical policies and criteria are current and applied consistently. Collaborates with Finance, Actuarial, Analytics, Quality, and Population Health teams to align clinical operations with organizational performance goals, STARs initiatives, and the annual bid cycle. Develops and executes strategies for managing complex patient populations across the continuum of care, with accountability for outcomes across the Triple Aim framework.

Formal Education Required :
a. Bachelor’s degree or equivalent experience required; Master’s degree in Healthcare Administration, Business Administration, Nursing, or related field strongly preferred.
b. Current Registered Nurse (RN) licensure in the State of Ohio, in good standing.

Experience and Training Required :
a. Seven (7) years of progressive healthcare leadership experience, to include:
i. Three (3) years in a director-level or equivalent role.
ii. Experience driving cost reduction and process improvement with quantifiable, documented results.
iii. Experience in a venture capital-backed or private equity-backed healthcare organization preferred.
iv. Demonstrated experience evaluating or deploying AI-based tools in a clinical or utilization management setting preferred.
v. Direct experience working within a Medicare Advantage plan in a clinical operations or UM leadership capacity preferred.
b. Certification in Care Management, Quality, Utilization Review, or a related clinical specialty preferred.
c. Lean, Six Sigma, or formal process improvement certification preferred.



3. Other Skills, Competencies and Qualifications:
a. Demonstrated track record of leading and completing change management initiatives in complex healthcare organizations.
b. Proven ability to identify problems, develop solutions, and execute independently without requiring direction.
c. Solid understanding of Medicare Advantage health plan operations, including CMS regulatory requirements, UM processes, care management, and the relationship between clinical performance and plan financial outcomes.
d. Working knowledge of InterQual clinical criteria and its role in UM nursing and physician review workflows.
e. Familiarity with CMS STARs ratings and how clinical operations contribute to measure performance, sufficient to collaborate effectively with STARs management teams.
f. Proficiency with clinical management platforms, analytics tools, and population health technology preferred. Familiarity with NCQA accreditation standards for UM and Case Management programs preferred.
g. Population Specific Competency: Ability to effectively interact with patients/customers with the understanding of their needs for self-respect and dignity

4. Level of Physical Demands:
a. Sedentary: Exerts up to ten pounds of force occasionally and/or a negligible amount of force frequently.