• Provide clinical leadership across utilization management, care management, population health, quality, pharmacy, medical policy, payment policy, and clinical program development • Partner with Health Plan senior leadership to advance clinical outcomes, affordability goals, growth targets, and overall health plan strategy • Lead cross-functional collaboration among Medical Directors, Medical Economics, Quality, Network, Compliance, Pharmacy, Operations, and Clinical Programs • Support compliance with government program requirements, including clinical appeals and grievances, using sound clinical evidence and medical judgment • Use clinical, quality, utilization, and financial data to identify trends, assess performance, and recommend actionable interventions • Develop strategies to improve medical expense management, appropriate utilization, quality of care, and population health outcomes • Provide clinical input into product design, Medicare bids, risk adjustment, STARS, HEDIS, value-based arrangements, and clinical integration initiatives • Communicate complex clinical, regulatory, and operational information clearly to executive, provider, clinical, and non-clinical audiences • Support appropriate utilization of services through strong partnership with Utilization Management, Care Management, and physician leaders • Represent the organization with regulatory entities, professional societies, providers, network partners, and external stakeholders, as appropriate • Build and strengthen relationships with hospitals, physicians, and other health care providers to support network engagement and performance goals • Support strategies tied to population health, care management, provider performance, and contractual outcomes • Lead, support, and develop physician leaders and clinical team members, as assigned

Role Description The Medical Management Clinician Senior will be responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. May collaborate with healthcare providers. Focuses on relatively complex case types that do require the training or skill of a registered nurse. Acts as a resource for more junior Clinicians. - Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear. - Serves as a resource to lower-level clinicians and staff. - May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes. - Assesses and applies medical policies and clinical guidelines within scope of licensure. - Conducts and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract. - May process a medical necessity denial determination made by a Medical Director. - Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members. - Refers complex or unclear reviews to higher level nurses and/or Medical Directors. - Does not issue medical necessity non-certifications. - Collaborates with leadership in enhancing training and orientation materials. - May assist leadership and other stakeholders on process improvement initiatives. - May help to train lower-level clinician staff. Qualifications - Requires H.S. diploma or equivalent. - Requires a minimum of 6 years of clinical experience and/or utilization review experience. - Current active, valid and unrestricted LPN/LVN or RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required; or any combination of education and experience which would provide an equivalent background. - Multi-state licensure is required if this individual is providing services in multiple states. Requirements - Virginia residency preferred. - RN license in the state applicant resides in is highly preferred. - Prior LTSS experience highly preferred. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). - Merit increases, paid holidays, Paid Time Off, and incentive bonus programs. - Medical, dental, vision, short and long term disability benefits. - Life insurance, wellness programs, and financial education resources.

• Define and execute Medicaid risk adjustment strategy across markets and plans • Lead and deliver high-impact strategic initiatives that improve revenue accuracy, compliance, and overall performance • Align risk adjustment programs with state Medicaid models (e.g., CDPS, CRG, or state-specific methodologies) • Represent risk adjustment Medicaid informatics in executive forums • Oversee health plan performance using advanced analytics and use proactive data insights to drive strategies and evidence-based decision-making • Lead development of scalable data pipelines and reporting frameworks using claims, encounters, pharmacy, and clinical data • Ensure accuracy, integrity and completeness of Medicaid encounter submissions and data • Establish and oversee processes to ensure accuracy, completeness, and integrity of risk capture • Direct suspecting logic development, gap identification, and prioritization strategies for operational programs and interventions • Lead and develop a high-performing, multidisciplinary team spanning informatics, risk analytics, reporting, and operational program support

Role Description The Medical Director is responsible for providing oversight, medical guidance and support to the full spectrum of WellSky’s clinical management acute, emergency department, and post-acute care solutions and programs. The scope of this job includes providing expertise and leadership in medical management, as well as care coordination activities for acute and post-acute care services. - Lead improvements of post-acute clinical programs by driving strategy, design, and implementation. - Provide timely expert medical review for acute (ED) and post-acute care services (SNF, IRF, LTACH, HH), provide a clinical opinion about the medical service under review (including post-decision reviews), and be available for escalations from the nurse teams. - Document clinical review findings, actions, and outcomes per policy and in accordance with regulatory and accreditation requirements. - Provide guidance for clinical operational aspects of the ED, acute, and post-acute care programs. - Collaborate with acute ED providers to coordinate and/or support care transitions. - Identify and develop opportunities for innovation to increase effectiveness and quality, including education development, training, and issue resolution. - Participate in client JOCs or partner/stakeholder meetings as needed. - Perform other job duties as assigned. Qualifications - Doctoral degree in a relevant medical field - At least 6-8 years of relevant work experience - Active, unrestricted medical license (MD or DO) - Board certification in a relevant specialty Requirements - Willing to travel up to 10% based on business needs - Willing to work additional or irregular hours as needed - Must work in accordance with applicable security policies and procedures to safeguard company and client information - Must be able to sit and view a computer screen for extended periods of time Benefits - Excellent medical with Rx, dental, and vision benefits - Mental Health support through EAP - Generous paid time off, plus 13 paid holidays - 100% vested 401(K) retirement plans - Educational assistance up to $2500 per year