The Clinical Director, Medical Management & Advocacy provides day-to-day clinical leadership and operational oversight for Utilization Review (UR), Case Management (CM), and Advocacy programs. This role partners closely with a Senior Clinical Director to execute strategy, ensure regulatory compliance, optimize clinical workflows, and deliver high-quality, member centered care. The Clinical Director serves as a key clinical leader supporting internal teams, vendor partners, and cross functional stakeholders.
Medical Management Program Oversight
- Oversee the operational performance of Medical Management programs, including Utilization Review, Case Management, and Advocacy.
- Ensure consistent execution of program workflows, service standards, and clinical protocols across internal teams and vendor partners.
- Partner with the Senior Clinical Director to implement clinical strategy through operational processes and program design.
Vendor & Operational Management
- Manage day-to-day Utilization Review and Case Management vendor operations, including performance monitoring, reporting, and issue resolution.
- Review vendor metrics, and quality indicators; identify and address performance gaps.
- Coordinate clinical escalations and large claimant workflows in collaboration with vendor partners and internal stakeholders.
Policy, Compliance & Governance
- Own and maintain Medical Management policies and procedures, ensuring operational alignment and regulatory compliance.
- Serve as the organization’s HIPAA Officer for Utilization Review, Case Management, and Advocacy functions.
- Support audits, accreditation activities, and regulatory reviews as they relate to Medical Management operations.
Team Leadership & Enablement
- Provide operational leadership and guidance to advocacy and clinical care teams, ensuring clarity of roles, workflows, and expectations.
- Support workforce planning, training, and operational readiness for Medical Management programs.
- Oversee 24/7 clinical helpline operations, including coverage models, escalation protocols, and quality oversight.