Director, Clinical Policy & Utilization Strategy

L.A. Care Health Plan; Los Angeles, Northern (CA, KY); Hybrid; USD 206,000 - 351,000; Full time

Benefits offered by this job

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Job summary

L.A. Care Health Plan is seeking a Medical Director, Clinical Policy in Los Angeles to lead the development, governance, and evaluation of clinical policies across the organization.

You will ensure policies are evidence‑based, compliant with regulatory requirements, and aligned with quality, safety, and member experience goals. You will oversee policy architecture, authorization strategies, and utilization oversight, collaborating across departments to support high‑quality and defensible medical

Qualifications

• Strategic leadership and analytical evaluation of clinical data and utilization metrics.
• Ability to translate evidence into administration and policy.
• Familiarity with CMS, Medi-Cal, DMHC, NCQA and related standards.

Responsibilities

• Provide executive clinical leadership in development, review, approval, and ongoing oversight of clinical policies and coverage criteria.
• Ensure policies comply with federal, state, and accreditation requirements and are clearly documented and applied.
• Monitor new medical technologies and external benchmarks to identify policy updates aligned with strategy.
• Oversee authorization strategy and utilization oversight across lines of business.
• Validate codes, rules, and clinical logic across systems while guiding regulatory compliance.
• Lead pre‑payment review and performance metrics for clinical decision‑making accuracy and timeliness.
• Guide the clinical criteria hierarchy and governance to mitigate fraud, waste, and abuse (FWA).
• Collaborate with stakeholders to support appropriate care delivery and align with utilization management and product development.

Skills

Strategic analytical thinker

Leadership presence

Regulatory compliance

Evidence-based practice

Healthcare policy

Education

Doctor of Medicine

Job description

L.A. Care Health Plan is seeking a Medical Director, Clinical Policy in Los Angeles to lead the development, governance, and evaluation of clinical policies across the organization.

You will ensure policies are evidence‑based, compliant with regulatory requirements, and aligned with quality, safety, and member experience goals. You will oversee policy architecture, authorization strategies, and utilization oversight, collaborating across departments to support high‑quality and defensible medical