Director, Medicaid Clinical Programs

Job Description

Job Description

Your Medicaid expertise. Meaningful impact. Join Alliant Health Solutions as Director of Medicaid Clinical Programs and help advance access, quality, and outcomes at an organization recognized among Atlanta’s Best Places to Work and Healthiest Employers.

The Director, Medicaid Clinical Programs provides clinical and operational leadership across Alliant’s Medicaid contracts and programs. The role oversees contract-specific functions that may include prior authorization, utilization and clinical review, quality improvement, compliance, provider oversight, claims review, and program integrity. Using clinical expertise, process improvement methods, and data analysis, the Director identifies risks and opportunities, translates requirements and findings into practical interventions, and improves access, quality, efficiency, compliance, and outcomes. The Director partners with clinical, programming, analytics, technology, and operations leaders to establish sustainable workflows. Knowledge of Medicaid delivery systems, including Fee-for-Service (FFS) and Managed Care Organizations (MCOs), is beneficial. 

ESSENTIAL JOB FUNCTIONS

• Lead analysis of clinical, operational, claims, quality, and performance data to identify trends, risks, compliance concerns, service gaps, root causes, and improvement opportunities across Medicaid programs.
• Provide strategic oversight and subject matter expertise for prior authorization and related clinical operations, including medical necessity criteria, review workflows, timeliness, quality, regulatory and accreditation compliance, provider and member experience, and operational performance.
• Lead contract-specific clinical and operational activities, including provider reviews and education, corrective-action follow-up, utilization and compliance reviews, claims review, provider oversight, and program integrity coordination, as required by assigned contracts.
• Partner with analytics teams to translate data into actionable priorities, interventions, dashboards, measures, and analytic products; monitor results and adjust improvement strategies.
• Lead process and quality improvement initiatives from assessment through implementation and monitoring to improve workflow reliability, turnaround times, clinical consistency, and outcomes.
• Develop clear reports, recommendations, and presentations for executives, customers, state Medicaid agencies, and other stakeholders.
• Collaborate with clinical, program, analytics, technology, and operations leaders to implement scalable, repeatable, and compliant processes and apply current clinical standards to program design, implementation, and evaluation.
• Maintain current knowledge of Medicaid requirements and delivery models, including FFS and managed care, relevant to assigned programs, customers, and contracts.
• Partner with Program Directors, the Medical Director, and the Chief Operating Officer on new business opportunities and organizational initiatives.
• Perform other duties as assigned.

OTHER JOB FUNCTIONS 

• Identify predictive insights and forward-looking opportunities for improvement and innovation, including appropriate use of AI tools to support analysis, workflow efficiency, and informed decision-making.
• Serve as a key presenter and thought partner with state Medicaid agencies and support business development and contract teams through proposals, presentations, and strategic discussions.
• Collaborate with organizational leaders to develop new projects, continuously improve operations, and strengthen Alliant’s credibility as a trusted advisor in Medicaid quality and performance improvement.
• Model teamwork, professionalism, effective communication, positive behavior, appropriate presence, and compliance with corporate and departmental policies.
• Protect the security and confidentiality of information in accordance with HIPAA, applicable laws and regulations, contract requirements, and company policies.

KNOWLEDGE, SKILLS, AND ABILITIES  

• Strong knowledge of team leadership, prior authorization, clinical review workflows, medical necessity criteria, and applicable regulatory and accreditation requirements.
• Broad knowledge of Medicaid clinical and operational functions, including utilization management, quality improvement, compliance, provider oversight, claims analysis, program integrity, state Medicaid policy, FFS, and managed care.
• Knowledge of process and quality improvement methodologies, with the ability to lead change from assessment through implementation and monitoring.
• Ability to apply clinical knowledge and sound judgment, analyze clinical and operational data, identify trends and root causes, and translate complex findings into priorities and actions.
• Excellent communication, interpersonal, facilitation, presentation, and critical-thinking skills, including the ability to communicate with nontechnical, executive, customer, and large-group audiences.
• Ability to lead cross-functional teams, work effectively at all organizational levels, manage concurrent projects, and meet deadlines.
• Proficiency with Microsoft Word, PowerPoint, and Excel.
• Valid driver’s license and ability to travel by car or airplane to customer locations and meetings as needed.

EDUCATION, EXPERIENCE, AND TRAINING

Required:

• Bachelor’s degree in nursing, public health, health administration, or a related field from an accredited college or university.
• Seven (7) to ten (10) years of healthcare experience, including prior authorization, utilization review or management, or comparable clinical review operations.
• Experience supporting multiple Medicaid programs or contracts in one or more relevant areas, including clinical review, quality improvement, provider oversight, compliance, claims review, or healthcare program integrity.
• Demonstrated success leading measurable process improvements and using clinical and operational data to establish priorities, guide action, and evaluate results.
• Strong understanding of healthcare quality measurement and improvement methodologies and demonstrated ability to lead and collaborate across clinical, analytics, technology, and operations teams.

Preferred:  

• Leadership experience in healthcare quality improvement, prior authorization, utilization management, or related operations.
• Experience with Medicaid programs, MCOs, and Healthcare Effectiveness Data and Information Set (HEDIS) measures.
• Clinical degree, licensure, or substantial clinical operations experience.
• Master’s degree in nursing, public health, health administration, or a related health field.
• National quality certification.

"If you're ready to put your clinical and operational expertise behind work that matters, we'd love to hear from you."

PHYSICAL REQUIREMENTS: Essential duties are routinely performed in a professional office environment but may be conducted in remote or field locations. The role may require work at a station/desk and routinely requires use of standard office equipment such as computers, phones, photocopiers/scanners, fax machines, printers, and filing cabinets. Duties may require use of transportation to attend meetings or conduct duties outside of the office environment. Must be able to regularly remain in a stationary position and occasionally move around the office to access office machinery and facilities. Occasionally, must be able to move/transport materials weighing up to 30 pounds, as well as position self to access files, equipment and work materials. This role frequently communicates to internal and external resources both verbally and written, via face-to-face, electronic, and telephonic media. Must be able to understand and exchange accurate information in these situations, as well as translate into action. Short-term and long-term memory, abstract reasoning, and decision making may be required on a regular basis. Core office / business operational hours may be required  

ADA/ADAAA/SECTION 503 NOTIFICATION:  In compliance with the ADA, the ADA Amendments Act (ADAAA) and Section 503 of the Rehabilitation Act), should you have a disability and would like to request a reasonable accommodation, please see Human Resources to begin the interactive process. 

  DISCLAIMER: This job description indicates the general nature and level of work expected of the incumbent. It is designed to cover or contain a comprehensive, but not all-inclusive, listing of activities, duties or responsibilities required of the incumbent. Incumbent may be asked to perform other duties as required.