• Oversight of clinical functions including utilization management, care coordination, and integrated care processes • Report to the Chief Medical Officer and collaborate with CEO, VP of Operations, Chief Compliance Officer, Chief Financial Officer, and other senior leadership • Develop and implement clinical strategies aligned with organizational goals • Establish policies and procedures and ensure compliance with CMS and accreditation standards • Perform reviews of operations and delegated entity decisions to determine medical appropriateness of inpatient and outpatient care • Provide telephonic utilization review, continued stay reviews, and utilization management based on clinical guidelines • Ensure evidence-based referral management, inpatient concurrent review, and care management to promote efficiency and regulatory compliance • Provide utilization and cost data measured against regional and external benchmarks • Complete UM delegation responsibilities • Manage and oversee the Care Management team and align programs with organizational goals • Collaborate with Social Work care managers, medical directors, and provider staff to coordinate care across the continuum • Advocate for patient needs, negotiate for services, and develop patient-centered care plans • Assess patient medical, behavioral health, and social determinants needs and prioritize care • Assist senior leaders with program design and write policies and procedures meeting CMS and accreditation standards • Lead audit activities including CMS Program audits for Organizational Determinations, Appeals and Grievances, and accreditation efforts • Report quality of care issues identified during utilization review according to policy • Promote and oversee performance improvement activities and complete annual HEDIS requirements • Summarize and analyze data, prepare statistical reports, and present monthly utilization management and care management reports to Senior Management • Collaborate with Care Management, Population Health, and Quality leaders and provide mentorship to clinical teams • Reasonable accommodations may be provided to enable individuals with disabilities to perform the essential functions.