Director of Clinical Operations
Description
The Director of Clinical Operations is a senior, hands-on leader responsible for overseeing day-to-day clinical and operational execution for UM and CM services across health plan, IPA, ACO and other clients as well as the CHS IPA/ACO. This role requires deep expertise in Utilization Management (UM), Care Management (CM), Quality, and clinical program implementation.
This individual operates with a high degree of autonomy, makes timely and confident decisions, and is deeply involved in operational details while maintaining accountability for outcomes, compliance, and client satisfaction in a fast-paced, high-growth environment.
FLSA Status | Exempt | Salary Range | $140,000- $180,000 |
Reports To | Principal | Direct Reports | Yes |
Location | Hybrid | Travel | Up to 25% |
Work Type | Regular | Schedule | Full Time |
Job Descriptions
Clinical Operations
• Provide direct oversight and operational leadership for Utilization Management and Care Management programs and activities, ensuring high-quality, compliance, and timely execution.
• Ensure consistent application of CM and UM policies, procedures, workflows, and evidence-based clinical criteria for UM (e.g., MCG, LCDs, NCDs, medical necessity guidelines).
• Monitor CM and UM program effectiveness and drive continuous improvement through data analysis, workflow optimization, and operational redesign.
• Serve as an escalation point for complex clinical determinations, operational issues, and regulatory concerns, making decisive, independent decisions as needed based on the clinical operations model for a particular client or the CHS IPA/ACO.
• Ensure all clinical operations comply with federal, state, and accreditation requirements, including delegated entity oversight and audit readiness.
Client Implementation & Onboarding
• Lead end-to-end onboarding for new and existing clients, including project planning, timeline management, performance improvement and coordination with internal and external stakeholders.
• Ensure accurate setup of systems, workflows, and compliance requirements.
• Conduct pre- and post-implementation reviews to guarantee smooth transitions.
Quality, Metrics & Performance Management
• Support quality improvement initiatives using objective and benchmark data, including utilization metrics, member outcomes, CAHPS, HEDIS, and Star Ratings where applicable.
• Develop, implement, and monitor robust operational, clinical, and outcome metrics across UM, Care Management, and implementation activities.
• Ensure services and deliverables are completed within expected timeframes and support internal and external quality audits.
Operational Excellence & Infrastructure
• Drive operational excellence through process improvement, standardization, automation, and scalable infrastructure.
• Oversee clinical systems integrity, upgrades, customization, and reporting to ensure efficiency, data accuracy, and regulatory compliance.
• Develop, review, and maintain clinical and operational policies and procedures aligned with current practices and regulatory requirements.
Cross-Functional Collaboration
• Partner with sales, clinical, operational, and IT teams to deliver consistent and exceptional client experience.
• Coordinate internal resources for operational support.
Qualifications
• Bachelor’s degree in nursing, Healthcare Management, or related field, or equivalent experience.
• 8–12+ years of progressive experience in Utilization Management, Medical Management, Clinical Operations, or Healthcare Operations, including senior leadership responsibilities.
• Deep, hands-on knowledge of UM operations, clinical criteria, and regulatory compliance.
• Experience leading client implementations and ongoing managed services in a health plan, TPA, MSO, consulting, or health tech environment.
• Proven ability to operate independently, manage ambiguity, and make timely, high-impact decisions.
• Strong experience developing operational workflows, performance metrics, and scalable processes.
Preferred Qualifications
• Clinical licensure (RN, MD, DO or equivalent) strongly preferred.
• Strong Health plan operations knowledge.
• Experience with Medicare, Medicaid, and/or commercial populations.
• Knowledge of delegated UM arrangements and audit processes.
• Experience working in or alongside technology-enabled clinical operations.
Core Competencies
• Strategic thinking and operational excellence
•Client-centric approach with a focus on service quality
•Leadership and team development
•Analytical and process improvement mindset
•Adaptability in a fast-paced environment
Benefits:
As a firm passionate about health care, we’re deeply committed to the health and wellness of our own team members. We offer comprehensive, affordable insurance plans for our team and their families, and a host of other unique benefits, such as a yearly stipend for wellness-related activities and a paid parental leave program. You can learn more about our benefits offerings here: https://copehealthsolutions.com/careers/why-cope-health-solutions/.
About COPE Health Solutions
COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit CopeHealthSolutions.com.
COPE Health Solutions is a national tech-enabled services firm powering success for health plans and for providers in risk arrangements. Our comprehensive NCQA certified population health management platform and highly experienced team brings deep expertise, experience, proven tools, and processes to improve financial performance and quality outcomes for all types of payers and providers. CHS de-risks the roadmap to advanced value-based payment and improves quality and financial performance for providers, health plans and self-insured employers. For more information, visit CopeHealthSolutions.com.
To Apply:
To apply for this position or for more information about COPE Health Solutions, visit us at https://copehealthsolutions.com/careers/open-positions/.