COPE Health Solutions · 22 hours ago
Director of Clinical Operations
California, United States
Full-time
Hybrid
Director/Executive
$140K/yr - $180K/yr
8+ years expCOPE Health Solutions is a national tech-enabled services firm powering success for health plans and providers in risk arrangements. The Director of Clinical Operations is responsible for overseeing day-to-day clinical and operational execution for Utilization Management and Care Management services, ensuring compliance, quality, and client satisfaction.
ConsultingHealth CareProfessional Services
Responsibilities
Provide direct oversight and operational leadership for Utilization Management and Care Management programs and activities, ensuring high-quality, compliance, and timely execution
Ensure consistent application of CM and UM policies, procedures, workflows, and evidence-based clinical criteria for UM (e.g., MCG, LCDs, NCDs, medical necessity guidelines)
Monitor CM and UM program effectiveness and drive continuous improvement through data analysis, workflow optimization, and operational redesign
Serve as an escalation point for complex clinical determinations, operational issues, and regulatory concerns, making decisive, independent decisions as needed based on the clinical operations model for a particular client or the CHS IPA/ACO
Ensure all clinical operations comply with federal, state, and accreditation requirements, including delegated entity oversight and audit readiness
Lead end-to-end onboarding for new and existing clients, including project planning, timeline management, performance improvement and coordination with internal and external stakeholders
Ensure accurate setup of systems, workflows, and compliance requirements
Conduct pre- and post-implementation reviews to guarantee smooth transitions
Support quality improvement initiatives using objective and benchmark data, including utilization metrics, member outcomes, CAHPS, HEDIS, and Star Ratings where applicable
Develop, implement, and monitor robust operational, clinical, and outcome metrics across UM, Care Management, and implementation activities
Ensure services and deliverables are completed within expected timeframes and support internal and external quality audits
Drive operational excellence through process improvement, standardization, automation, and scalable infrastructure
Oversee clinical systems integrity, upgrades, customization, and reporting to ensure efficiency, data accuracy, and regulatory compliance
Develop, review, and maintain clinical and operational policies and procedures aligned with current practices and regulatory requirements
Partner with sales, clinical, operational, and IT teams to deliver consistent and exceptional client experience
Coordinate internal resources for operational support
Qualification
Required
Bachelor's degree in nursing, Healthcare Management, or related field, or equivalent experience
8–12+ years of progressive experience in Utilization Management, Medical Management, Clinical Operations, or Healthcare Operations, including senior leadership responsibilities
Deep, hands-on knowledge of UM operations, clinical criteria, and regulatory compliance
Experience leading client implementations and ongoing managed services in a health plan, TPA, MSO, consulting, or health tech environment
Proven ability to operate independently, manage ambiguity, and make timely, high-impact decisions
Strong experience developing operational workflows, performance metrics, and scalable processes
Preferred
Clinical licensure (RN, MD, DO or equivalent) strongly preferred
Strong Health plan operations knowledge
Experience with Medicare, Medicaid, and/or commercial populations
Knowledge of delegated UM arrangements and audit processes
Experience working in or alongside technology-enabled clinical operations
Benefits
Comprehensive, affordable insurance plans for our team and their families
Yearly stipend for wellness-related activities
Paid parental leave program
Company
COPE Health Solutions
COPE Health Solutions is a national mission-driven consulting firm that partners with health system and payer clients and provides.
51-200 employees
Funding
Current Stage
Growth StageTotal Funding
$7.5MKey Investors
MindTree
2022-04-05Series A· $7.5M
Leadership Team
Allen Miller
Principal & CEO
Recent News
2025-08-13
2025-04-02
2024-05-20
Company data provided by crunchbase