Medix™
We are seeking a dynamic Director of Clinical Operations to lead and oversee key clinical functions including utilization management, care coordination, and integrated care processes. Reporting to the Chief Medical Officer, this role will partner closely with the CEO, VP of Operations, Chief Compliance Officer, CFO, and other senior leaders to design and execute clinical strategies that support organizational growth and operational excellence.
This leader will play a critical role in building scalable clinical infrastructure, establishing policies and procedures, ensuring CMS and accreditation compliance, and driving performance improvement initiatives. Experience in a start-up or growth-stage health plan environment and passion for building sustainable, scalable operations is essential.
Key Responsibilities Utilization Management & Clinical Oversight Oversee utilization management activities and delegated entity performance to ensure appropriate, evidence-based care delivery. Conduct reviews of inpatient and outpatient services using clinical guidelines and benefit determinations. Support utilization review, concurrent review, referral management, and care management functions in alignment with regulatory requirements. Provide utilization and cost reporting benchmarked against internal and external standards. Fulfill UM delegation oversight responsibilities.
Care Coordination & Integrated Care Lead and support the Care Management team to ensure alignment with organizational goals. Collaborate with social work, medical directors, behavioral health partners, and provider networks to coordinate care across the continuum. Advocate for patient needs and support development of person-centered care plans. Assess medical, behavioral, and social determinant needs to prioritize care and close knowledge gaps.
Policy Development & Compliance Develop and refine policies and procedures that meet CMS and accreditation standards. Ensure compliance with federal and state regulations in daily operations. Lead audit readiness activities, including CMS program audits, accreditation, and regulatory reviews. Identify and report quality-of-care issues in alignment with policy.
Performance Improvement & Reporting Champion performance improvement initiatives and data-driven operational enhancements. Support HEDIS activities and quality management programs. Analyze utilization and quality data, prepare reports, and present findings to senior leadership. Align initiatives with organizational strategy, NCQA standards, and regulatory requirements.
Collaboration & Leadership Partner with leaders across Care Management, Population Health, and Quality to align clinical operations. Participate in committees and task forces as needed. Mentor and develop clinical teams, fostering a culture of excellence and continuous improvement.
Required Qualifications Active Massachusetts RN license 3–5 years of Utilization Management experience 2+ years of Care Management experience Prior health plan experience (small plan experience preferred) Demonstrated leadership experience
Preferred Qualifications Experience with Medicare Advantage operations and CMS audit readiness Background in clinical quality and performance improvement using KPIs and dashboards Familiarity with InterQual, MCG, or Milliman criteria Proven success scaling clinical teams and leading operational change Experience collaborating with medical leadership, compliance, and operations
This leader will play a critical role in building scalable clinical infrastructure, establishing policies and procedures, ensuring CMS and accreditation compliance, and driving performance improvement initiatives. Experience in a start-up or growth-stage health plan environment and passion for building sustainable, scalable operations is essential.
Key Responsibilities Utilization Management & Clinical Oversight Oversee utilization management activities and delegated entity performance to ensure appropriate, evidence-based care delivery. Conduct reviews of inpatient and outpatient services using clinical guidelines and benefit determinations. Support utilization review, concurrent review, referral management, and care management functions in alignment with regulatory requirements. Provide utilization and cost reporting benchmarked against internal and external standards. Fulfill UM delegation oversight responsibilities.
Care Coordination & Integrated Care Lead and support the Care Management team to ensure alignment with organizational goals. Collaborate with social work, medical directors, behavioral health partners, and provider networks to coordinate care across the continuum. Advocate for patient needs and support development of person-centered care plans. Assess medical, behavioral, and social determinant needs to prioritize care and close knowledge gaps.
Policy Development & Compliance Develop and refine policies and procedures that meet CMS and accreditation standards. Ensure compliance with federal and state regulations in daily operations. Lead audit readiness activities, including CMS program audits, accreditation, and regulatory reviews. Identify and report quality-of-care issues in alignment with policy.
Performance Improvement & Reporting Champion performance improvement initiatives and data-driven operational enhancements. Support HEDIS activities and quality management programs. Analyze utilization and quality data, prepare reports, and present findings to senior leadership. Align initiatives with organizational strategy, NCQA standards, and regulatory requirements.
Collaboration & Leadership Partner with leaders across Care Management, Population Health, and Quality to align clinical operations. Participate in committees and task forces as needed. Mentor and develop clinical teams, fostering a culture of excellence and continuous improvement.
Required Qualifications Active Massachusetts RN license 3–5 years of Utilization Management experience 2+ years of Care Management experience Prior health plan experience (small plan experience preferred) Demonstrated leadership experience
Preferred Qualifications Experience with Medicare Advantage operations and CMS audit readiness Background in clinical quality and performance improvement using KPIs and dashboards Familiarity with InterQual, MCG, or Milliman criteria Proven success scaling clinical teams and leading operational change Experience collaborating with medical leadership, compliance, and operations