What we're looking for in our
Director of Clinical Services You are a strategic clinical leader who thrives on building high-performing teams, transforming healthcare operations and creating better experiences and outcomes for members. You bring deep expertise in clinical services, utilization management and care management, but you're equally passionate about innovation, continuous improvement and helping teams perform at their best.
You excel at turning strategy into action. Whether you're improving workflows, implementing new technologies, developing clinical programs or leading operational transformation, you're energized by solving complex challenges and driving measurable results. You know how to balance clinical quality, operational efficiency and member outcomes while keeping people at the center of every decision.
Collaboration comes naturally to you. You're comfortable working across departments, influencing stakeholders, coaching teams and building strong relationships that move initiatives forward. You understand that healthcare delivery is evolving rapidly, and you see technology, data and AI-enabled tools as opportunities to elevate both the member and employee experience.
Why this role matters to our organization:
You will play a critical role in shaping the future of BCBS Global Solutions' clinical services organization-transforming traditional utilization management and care management functions into an integrated, member-centered model that improves outcomes, enhances the healthcare experience and delivers measurable value.
Here's the work you'll be doing to shape our clinical services:
Lead & Develop- Lead the day-to-day operations of the Medical Review Team, including Utilization Management, Case Management and other assigned clinical services.
- Lead quality assurance and continuous improvement activities, including audits, trend analysis and performance improvement initiatives.
- Establish operational priorities and ensure delivery of high-quality, timely and compliant clinical services.
- Monitor clinical and operational performance metrics, including productivity, quality, service levels and turnaround times.
- Use workforce, operational and performance data to identify opportunities for continuous improvement and support achievement of business objectives.
- Hire, coach, mentor and develop a high-performing clinical team.
- Foster a culture of accountability, innovation, collaboration and continuous improvement.
- Coordinate staffing, scheduling and operational coverage for our 24/7 clinical environment.
Shape & Transform - Partner with the Senior Medical Director to execute our clinical strategy and long-term vision.
- Design, implement and continuously improve clinical programs that enhance quality, health outcomes and member experience while supporting sustainable medical cost management.
- Help transform clinical operations into a proactive, member-centered care navigation model.
- Build integrated clinical workflows that connect members with care management programs, digital health solutions, providers and healthcare resources.
- Identify opportunities for innovation, automation, predictive analytics and emerging care models.
Collaborate & Influence - Partner closely with teams across Clinical Services, Customer Service, Claims, Global Networks, Product, Technology, Analytics and other business functions.
- Support implementation of provider steering, population health, disease management and preventive health initiatives.
- Provide leadership and expertise on enterprise-wide projects and strategic initiatives.
- Ensure clinical operations align with organizational goals, accreditation standards and regulatory requirements.
What success in this role looks like
As Director of Clinical Services, you will be responsible for driving measurable improvements across our clinical operations and care management programs.
Success in this role will be demonstrated through improvements in:
- Clinical quality and consistency of medical reviews
- Member outcomes, engagement and experience
- Sustainable medical cost management
- Productivity, workforce utilization and operational efficiency
- Service levels, turnaround times and quality assurance performance
- Adoption and effectiveness of clinical programs, provider steering and digital health solutions
- Employee engagement, development and team performance
You will leverage data, performance metrics, technology and continuous improvement methodologies to evaluate results, identify opportunities and ensure our clinical programs deliver meaningful value for members, providers and the organization.
This might be the right fit for you if...
- You thrive in a dynamic, fast-paced environment and can effectively balance competing priorities while supporting a global operation that serves members around the clock.
- You hold a current, active and unrestricted clinical license (RN, NP, PA, Pharmacist or other licensed healthcare professional) in good standing within a U.S. jurisdiction.
- You have at least 10 years of progressive healthcare experience, including significant leadership experience in clinical operations, utilization management, case management or care management programs.
- You have experience leading multidisciplinary clinical teams and driving operational excellence.
- You hold a master's degree in Nursing, Healthcare Administration, Public Health, Business Administration or a related field.
- You have experience implementing and managing clinical programs within health insurance or managed care environments.
- You understand healthcare analytics and know how to use data and KPIs to improve performance and outcomes.
- You are comfortable leading change, adopting new technologies and implementing innovative approaches to clinical care delivery.
- You communicate effectively with frontline teams, senior leaders and cross-functional stakeholders.
- Bonus points if you have experience supporting healthcare delivery outside the United States or have significant international healthcare, travel or expatriate experience.
What you'll get in return:- Competitive base pay + annual bonus
- Competitive medical plans
- Telemedicine available
- Paid parental leave
- Employee assistance and wellness support 24/7
- Free international healthcare coverage
Other Great Perks: - Hybrid work model
- Work abroad arrangements available
- Generous PTO accrual program with carry-over option
- 9 paid holidays in addition to one floating holiday and one volunteer day
- Tuition reimbursement
- Career/Learning and development opportunities
- 401(k) with generous company match
- Pet insurance offerings
- Identify theft and legal coverages available
- Emphasis on well-being (Virtual well-being platform, monthly mindfulness events, and giveaways)
