Serves as the primary clinical execution partner for EHP's population health and VBC strategy.
Drives strategy and execution across core clinical key results: cost trend management, high-cost member intervention, care management, utilization oversight, and HEDIS quality gap closure.
Leads high-priority clinical initiatives focused on chronic conditions, maternity/pediatric quality, ED/hospital utilization, behavioral health.
Oversees UM activities in partnership with the TPA, including prior authorization oversight, level of care determination, clinical criteria application, and utilization trend monitoring.
Leads complex patient case reviews for high-priority and high-cost members, providing clinical judgment, care plan direction, and escalation management.
Governs disease management programs across cardiac, oncology, behavioral health, MSK, diabetes, CKD, and obesity populations.
Oversees transitions of care protocols and enforce care management partner SLA accountability.
Serves as EHP's primary clinical point of contact for all care management, UM, and care gap closure vendor partners.

Active, unrestricted RN licensure in the State of Georgia.
Minimum 7 years of progressive clinical operations leadership in a health plan, managed care, or equivalent VBC setting.
Demonstrated track record leading population health programs: disease management, high-risk member intervention, care gap closure, and quality improvement.
Strong UM experience including prior authorization oversight, level of care determination, and TPA clinical operations oversight.
Proven ability to independently navigate claims data, population health dashboards, and financial reports without relying on analyst support.
Experience holding clinical vendors accountable to SLAs, conducting independent data validation, and leading formal performance reviews.

Director, Clinical Operations, Population Health

Key skills