Program Manager - Clinical Operations

Role Description

The Program Manager – Clinical Operations is responsible for leading strategic programs and operational initiatives supporting Care Management, Utilization Management, Care Coordination, Population Health, and Value-Based Care services. This role will drive program execution, operational excellence, quality improvement, and performance outcomes across clinical operations while ensuring alignment with organizational goals and client expectations.

Key Responsibilities

• Program Leadership & Execution
  • Lead end-to-end management of clinical operations programs, including planning, implementation, monitoring, and optimization.
  • Manage multiple workstreams supporting care management, utilization management, transitions of care, chronic disease management, and population health initiatives.
  • Establish program governance, project plans, milestones, and performance metrics.
  • Ensure timely delivery of strategic initiatives while meeting quality, operational, and financial objectives.
• Clinical Operations Management
  • Collaborate with clinical leadership to improve care management workflows and operational processes.
  • Drive initiatives focused on reducing avoidable admissions, readmissions, emergency department utilization, and total cost of care.
  • Support implementation and enhancement of clinical programs targeting high-risk and complex populations.
  • Ensure operational readiness for new client implementations, program expansions, and process transformations.
• Population Health & Value-Based Care
  • Support value-based care initiatives through performance monitoring and outcome improvement strategies.
  • Utilize healthcare analytics to identify care gaps, risk trends, utilization patterns, and intervention opportunities.
  • Partner with quality and clinical teams to improve HEDIS, STAR, and other quality performance measures.
  • Monitor key population health metrics and recommend improvement actions.
• Stakeholder & Client Management
  • Serve as a primary point of contact for internal and external stakeholders.
  • Facilitate collaboration across clinical, operational, technology, quality, and analytics teams.
  • Present program performance, operational updates, risks, and recommendations to leadership and clients.
  • Build strong relationships with healthcare payer, provider, and care management stakeholders.
• Quality & Regulatory Compliance
  • Ensure adherence to NCQA, CMS, HIPAA, URAC, and client-specific requirements.
  • Support audit readiness and regulatory compliance activities.
  • Monitor operational quality metrics and implement corrective action plans when necessary.
  • Promote a culture of continuous quality improvement.
• Performance Management & Analytics
  • Develop and monitor KPIs, operational dashboards, and program scorecards.
  • Analyze trends related to productivity, utilization, quality outcomes, and member engagement.
  • Identify opportunities for operational optimization through data-driven decision-making.
  • Provide executive-level reporting and actionable insights.
• Risk & Change Management
  • Identify program risks, operational challenges, and process gaps.
  • Develop mitigation strategies and manage change initiatives across teams.
  • Ensure effective communication and stakeholder engagement throughout program implementation.

Qualifications

• Bachelor's degree in Healthcare Administration, Nursing, Public Health, Life Sciences, Business Administration, or a related field.
• 7+ years of experience in healthcare operations, care management, utilization management, population health, or clinical program management.
• 3+ years of experience leading cross-functional programs or large-scale operational initiatives.
• Strong understanding of healthcare payer and provider operations.
• Experience working with clinical and operational performance metrics.

Preferred Qualifications

• Master's degree (MBA, MHA, MPH, MSN, or equivalent).
• PMP, Lean Six Sigma, PMP, or Healthcare Quality certifications.
• Experience with Value-Based Care, Risk Adjustment, Population Health Management, HEDIS, STAR Ratings, or Care Management programs.
• Familiarity with EMR/EHR systems, care management platforms, and healthcare analytics tools.

Core Competencies

• Program & Portfolio Management
• Clinical Operations Leadership
• Population Health Management
• Utilization & Care Management
• Value-Based Care Strategy
• Healthcare Analytics & Reporting
• Process Improvement & Operational Excellence
• Stakeholder & Client Management
• Regulatory Compliance
• Change Management
• Strategic Thinking & Problem Solving

Key Performance Indicators (KPIs)

• Program delivery within scope, timeline, and budget.
• Improvement in care management and utilization outcomes.
• Reduction in avoidable admissions and readmissions.
• Enhanced quality measure performance (HEDIS, STAR, CMS metrics).
• Client satisfaction and operational performance targets.
• Operational efficiency and productivity improvements.
• Compliance and audit readiness outcomes.

Location

View email address on remotive.com USA, United States of America