Executive Leader, Utilization Management & Clinical Ops

EmblemHealth; New York (NY); On-site; USD 325,000 - 400,000; Full time

Job summary

EmblemHealth seeks a senior clinical operations leader to redesign and oversee Utilization Management across Medicaid, Commercial, and Medicare. You will lead a large UM team and external vendors, shaping strategy to improve access to medically necessary care and strengthen provider and member experience.

Responsibilities include driving enterprise UM transformation, vendor oversight, regulatory compliance, and data-driven performance improvements to align with quality and affordability goals.

Qualifications

• 10+ years of progressive physician leadership experience in utilization management or clinical operations.
• 8-12+ years in commercial health insurance and/or employee benefits with product strategy or strategic sales advisory.
• 7+ years of senior leadership building and managing multi-disciplinary teams.

Responsibilities

• Lead the strategic redesign, operational performance, and day-to-day management of UM across Medicaid, Commercial, and Medicare.
• Provide executive leadership for approximately 250 UM staff and external vendors; ensure timely, clinically appropriate decisions.
• Modernize UM operating model with data-driven approaches and governance to improve access, affordability, and outcomes.

Skills

Executive leadership

Clinical leadership

Data-driven decisions

Vendor management

Regulatory compliance

Cross-functional collaboration

Strategic communications

Education

MD/DO licensed physician

MBA or advanced degree preferred

Job description

EmblemHealth seeks a senior clinical operations leader to redesign and oversee Utilization Management across Medicaid, Commercial, and Medicare. You will lead a large UM team and external vendors, shaping strategy to improve access to medically necessary care and strengthen provider and member experience.

Responsibilities include driving enterprise UM transformation, vendor oversight, regulatory compliance, and data-driven performance improvements to align with quality and affordability goals.