Director, Clinical Operations

Middletown RI 02842

Job Description

Maintains operational accountability for care coordination, case management, disease management, health promotion and peer support functions to achieve the business and clinical outcomes for the health plan, meeting contract requirements. Directs all care coordination activities ensuring delivery is consistent with model of care, approved program descriptions and meets state, National Committee of Quality Assurance (NCQA) accreditation standards, Centers for Medicare and Medicaid Services (CMS), and other applicable standards and requirements.

Essential Functions

-Plans, implements, directs and provides leadership and oversight of the clinical and care coordination operational processes and staff.
-Actively participates in cost of care and medical action plan activities.
-Actively participates in regulatory, quality management, performance management and accreditation activities.
-Acts as Subject Matter Expert for case coordination and care management programs that care coordination and care management team activities meet the standards required for the state, NCQA, CMS and other accreditation and oversight entities.
-Directs, coordinates and oversees the evaluation of efficiency and productivity of care coordination functions, including complex case management, chronic disease programs, health promotion for physical and behavioral health as well as the work of peer support specialists and health guides.
-Assures staff selection, training, and evaluation to promote the development of a high quality team.
-Collaborates and coordinates with departmental managers to integrate and communicate with and across the utilization management and quality programs.
-Participates in the evaluation of the care coordination program against quality and utilization benchmarks and goals. Identifies opportunities for improvement.
-Works closely with and provides input to national health plan clinical team on program design, policies, procedures, workflows, and correspondence.
-Collaborates with leaders in Network, Community Liaison, Quality Improvement, Customer Service and Finance to assure a comprehensive approach to managing quality of care, service and cost of care.


General Job Information


Director, Clinical Operations



Job Family

Clinical Services Group


United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date


Date Requisition Created


Minimum Qualifications


Bachelors: Nursing (Required)

License and Certifications - Required

RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

CCM - Certified Case Manager - Care Mgmt

Other Job Requirements


Must have experience overseeing contractual performance standards. Experience with reporting and analyzing managed care utilization data. Must 2+ years experience in care coordination and case management operations.Minimum 5 years managed care and Medicaid experience. Minimum 3 years direct supervisory experience including responsibility for analyzing cost of care results, cost of care opportunities, quality measurement and performance metric development and achievement.Accreditation and Quality Improvement experience.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled

“I receive a high level of support from our Senior Management Team to execute on our vision. They are always accessible and approachable, something I’ve found to be very unique to Magellan.”